Applicant Name:

Address: City: State: Zip:

Telephone: (H)    (W)

Email Address (club email will be sent here)

Which information may we share with club members?  Check ALL boxes that apply.

Paper Copy:    Name/Address:    Phone: (H)  (W)     Email:     Don't Share:

Club Website:  Name/Address:    Phone: (H)  (W)     Email:     Don't Share:

Membership Type:    Single ($25.00 per year)        Family ($35.00 per year)

For family memberships, please list other family members by name:

Emergency Contact:

Name: Relation: Phone:

I hereby appoint  Stingray Divers Club and any member therein to perform necessary acts deemed desirable in connection with planning and leading any trip or social event on my behalf.  I fully understand that Stingray Divers Club is a voluntary association run by volunteer officers and board members.  By participating I accept full responsibility for any consequences my actions may cause.  I realize that SCUBA as well as many other activities have innate dangers that may result in physical injury and/or death.  I hereby release Stingray Divers Club from any liability in connections with injuries I, or my family, may incur in relation to participation in any event.

Signature: Date:

New Member:  Renewal:    Records Update:    Dues Received: $   Check: Cash:   

Club Use Only - Do Not Enter Information Below This Line.

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