Application in word format E-mail application to FtWayneDiveClub@aol.com
FORT WAYNE DIVE CLUB, INC
APPLICATION FOR MEMBERSHIP
NAME_____________________________________________________________
ADDRESS__________________________________________________________
CITY_______________________STATE_______ ZIP CODE_________________
DATE OF BIRTH___________________ PHONE_________________________
MARITAL STATUS_________________ SPOUSE________________________
EMPLOYER_______________________ WORK HOURS__________________
DIVING CERTIFICATION___________ CERT #_________________________
DATE OF CERTIFCATION__________ APROX # OF DIVES______________
TYPE OF DIVING EXPERENCE________________________________________
ARE YOU A MEMBER OF ANY OTHER DIVE CLUB Y / N
IF YES WHICH ONES AND WHERE? ___________________________________
DO YOU HAVE ANY PHYSICAL CONDITIONS AFFECTING YOUR ABILITY TO DIVE? _______________________________________________________________
ARE YOU TAKING ANY MEDICATIONS OR DRUGS? ______________________
ARE YOU ALLERGIC TO ANY MEDICATIONS OR DRUGS? _______________
DO YOU HAVE ANY ALLERGIES? _______________________________________
PHYSICIANS NAME______________________ PHONE #____________________
PLEASE LIST NAMES AND PHONE NUMBERS OF SOMEONE TO CONTACT IN THE EVENT OF AN EMERGENCY
NAME____________________________ RELATIONSHIP____________________
PHONE #__________________________ PHONE #__________________________
NAME____________________________ RELATIONSHIP____________________
PHONE #__________________________ PHONE #__________________________
OTHER HOBBIES OR INTEREST_________________________________________
I affirm that the above data is true and hereby affix my signature in acknowledgement thereof:
_________________________________________
PRINTED NAME
__________________________________________________
SIGNATURE
___________________________ ___________________________________
WITNESS WITNESS
PLEASE ATTACH A COPY OF YOUR C-CARD FOR CLUB RECORDS
Club use: Type of membership________________Member since_______________
Date___________________ Secretary____________________________