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Please download both the application & waiver to join the SunCoast Reef Rovers. Application Name:______________________________________________________________ Address:____________________________________________________________ City:______________________________________ Zip Code:_________________ Phone Number: Home:_____________________ Work:______________________ e-mail:_____________________ Fax #:______________________ Spouse / Alternative Other:________________________________________________________ Alternate Phone Number Home:________________________ Work:_______________________ Diving Information Certification Level:_____________________________________C Card Number: _______________________________________ Dive Interests: ________________________________________ ________________________________________ General Information Emergency Contact:____________________________________Emergency Phone #:____________________________________ Medical Insurance Carrier:________________________________ Medical Insurance #:____________________________________ Dive Insurance Carrier:___________________________________ Dive Insurance Card #:___________________________________ Medical Conditions:_____________________________________ _____________________________________ Application Information Application Fee:________________________________________Application Date:_______________________________________ Cash:_____________ Check #:____________________________ Received By:__________________________________________ Membership promotes: Safety, Education, Technical Assistance,
Environmental Awareness Please attach copies of certification / dive insurance card Mail application & waiver to SunCoast Reef Rovers, Inc. 708 Apalachicola Rd. Venice, FL 34285 |
