Form

Bluegrass Dive Club
Lexington, Kentucky

Membership Application Form

Bluegrass Dive Club
Membership Application/Directory Update

Check One:	New Member Directory Update
Name:
Nickname:	Birth date:
Home Phone:
Home Address:
City:	State: Zip:
Home E-Mail Add:
Include in Directory?	YES NO Information will be available to other members only
Occupation:
Company:
Business Phone:	Extension:
Business Address:
City:	State: Zip:
Business E-Mail Add:
Certification Level:	Agency:
How did you find us:	(Hold Ctrl for multiple selections)
Specialties: Remarks/Comments: or Address if Non-US:
CPR Certified?:	Yes No Expiration Date:
Membership Type:	Click HERE for explanation of Membership Types
Following for Family memberships only - please list additional family members
NAME	Diver?	Email Address**	DOB*	Include in Directory
1st additional family member
	Yes No			Yes No
2nd additional family member
	Yes No			Yes No
3rd additional family member
	Yes No			Yes No
4th additional family member
	Yes No			Yes No
* To determine voting eligibility ** Leave blank if family member does not wish to receive newsletter or announcements

For a Microsoft� Word printable version of this form - Click Here

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This Page was last modified09/06/22