TESTING MODE – Please do not fill out this form! Membership Signup Form Choose a User name and passwordUsername*Password Enter Password Confirm Password Personal InfoName* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Birthday* Age*What are you looking for in a dive club?*When are you available for club dives/activities?* Nights Weekends Days All the time! Are you currently certified to dive?* Yes No Level of certification:Date certified Certifying agency:Are you interested in furthering your current level of education?YesNoAre you member of Divers Alert Network (D.A.N.)?YesNoAre you a student? (of diving) Yes No Approximately, how many dives have you made?*Deepest dive to date (feet):Have you ever made a Decompression dive?*YesNoWhat are your diving interests? (check all that apply) Wreck Diving Artifact Collectioning Spear Fishing Night Diving Deep Diving Beach Diving U/W Photography Environmental Issues Would you be interested in participating in club committees?*YesNoAre you First aid/CPR certified?*YesNoDo you want your name, phone number, and email included on a roster to be sent to other club members?*YesNoDo you prefer to receive your club newsletter via email?*YesNoAre you a member of other clubs?*YesNoWhich one(s)?How did you hear about The Dive Club?*RELEASE OF LIABILITYI hereby affirm that I have been advised and thoroughly informed through my open water training of the inherent risks of skin and scuba diving.* I agree I understand that diving with compressed air involves certain inherent risks; decompression sickness; embolism, or other hyperbaric injuries can occur that require treatment in a recompression chamber. I further understand that any trips of any kind (diving or non-diving), whether sponsored or not, by The Dive Club may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still clioose to proceed with such diving activities in spite of the absence of a recompression chamber in proximity to the dive site(s).* I agree I understand and agree that neither The Dive Club or any of their respective board members, officers, agents or. assigns (hereinafter referred to as "Released Parties"), may be held liable or responsible in any way for any injury, death, or other damages to me or my family, heirs, or assigns that may occur as a result of my participation in any Dive Club activity, or as a result of the negligence of any party, including the Released Parties, whether passive or active.* I agree In consideration of being allowed to become a member of The Dive Club I hereby personally assume all risks in connection with any diving or non-diving activity from any harm, injury or damage that may befall on me, including all risks connected therewith, whether foreseen or unforeseen.* I agree I further understand that skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during any diving activity, and that if I am injured as a result of a heart attack, panic, hyperventilation, etc., that I expressly assume the risk of said injuries and that I will not hold the above listed individuals or companies responsible for the same.* I agree I further state that I am of lawful age and legally competent to agree to this liability release, or that I have acquired the written consent of my parent or guardian.* I agree I understand that the terms herein are contractual and are not a mere recital, and that I have agreed to this document of my own free act.* I agree I completely agree to exempt and release The Dive Club, and all related entities as defined above, from any and all liability or responsibility whatsoever for personal injury, property damage or wrongful death however caused, including, but not limited to, the negligence of the released parties, whether passive or active. I have fully informed myself of the contents of this liability release and express assumption of risk by reading it before I agreed to it on behalf of myself and my heirs.* I agree Please enter your full name, which will serve as your signature attesting to all of the above statements that you "agreed" to.*Choose Your Membership Level (individual or family)Membership Level*New Membership - IndividualNew Membership - FamilyPlease enter the names of family membersTotal $0.00 Please upload a copy of your certification card. Drop files here or
