Name: __________________________________________________________________

Mailing Address: __________________________________________________________

City, State, Zip Code: _______________________________________________________

Home Phone: ______________________Cell Phone: _____________________________

E-mail___________________________________________________________________

TYPE OF MEMBERSHIP:  Family_______             Single______

Spouse Name: ___________________  Diver __or NonDiver__

Children’s Name(s): _________________ Diver__or NonDiver__

                             _________________ Diver__or NonDiver__

                             _________________ Diver__or NonDiver__

Membership Rates:  Single Membership  $30/year (18 years or older)

                                 Family Membership $40/year (18 years or older)