EMERALD SEA DIVE CLUB MEMBERSHIP APPLICATION

Name (first & last)________________________________e-mail address(opt)_____________
Address_____________________________City___________________State_____Zip________
Home phone (_____)_______________Work phone (not required) ( _____)_______________
Date of Birth _______________ How long have you been diving?__________
Certification Agency/Level/Number ____________________________________ .
Approximate number of dives: __________ Boat Dives?_________ Night Dives? ______
Favorite dive location(s) _________________________________________________ .
How did you hear about the club? _____________________________________________ .
Do you have any medical problems that could affect your diving or participation in club activities? __________________________________________________________ .
Person to notify in case of an emergency _______________________________ ,
Phone (_____) _______________ Relationship _______________ .
Are you an insured member of DAN? _________ Membership # ______________

(___) Check here if interested in participating in the "Big Buddy Program"

I HEREBY ACKNOWLEDGE that SCUBA/skin diving can be dangerous. The possibility of serious injury or death is present. The proper use of equipment and techniques can be used to greatly minimize these risks. Emerald Sea Dive Club promotes safe diving practices in its activities, but cannot guarantee that accidents will not occur.

I FURTHER ACKNOWLEDGE that it is the responsibility of each diver to ensure that they follow accepted diving practices and to maintain the safety of their own diving equipment. Each diver should evaluate each diving situation with respect to their skill level and decline to participate if there is any doubt of performing a safe dive.

I FURTHER ACKNOWLEDGE that by participating in Emerald Sea Dive Club events, and in signing this release, each member takes responsibility for their own actions. Emerald Sea Dive Club accepts no liability for injury or death that may occur during club activities.

I DO HEREBY AGREE TO HOLD HARMLESS AND INDEMNIFY the Emerald Sea Dive Club, its members or its officers, including but not limited to club members who provide their boats for club activities, for any injuries or damages that I, my equipment, my family, heirs or assigns may suffer as a result of Emerald Sea Dive Club activities, including SCUBA/skin diving

The scope of this indemnity and hold harmless agreement includes both ordinary and gross negligence.

SIGNATURE _________________________________ DATE _______________

Additional Comments: ______________________________________________________

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