Michigan Underwater Divers Club
This is a volunteer organization and relies on our members to donate their time in support of our various activities.
PERSONAL DATA (Please Print Clearly)
Name: __________________________________ Date: _________________
Address: ______________________________________________________
City: ________________________________ State: ______ Zip: ___________
Home Phone: (______) _________________ Cell Phone: ________________
E-mail: ______________________ Over 18: Yes / No DAN Member: Yes / No
DIVING CERTIFICATION AND EXPERIENCE:
Certifying Agency: ____________________ Cert. No.: _________ Date: ________
Highest Level of Certification: ____________ Cert. No.: _________ Date: ________
How Many Dives: ________ State where you were certified: ___________________
Certifying Instructor: ____________________________________________________
Proof of diving certification must be presented with application.
Type of diving you like: (ie: boat, shore, grubbing, wreck, river, quarry, cavern, treasure hunting, photo/video, ice, etc.)
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Types of Dives during the past two years:
_____________________________________________________________
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FAMILY MEMBERS
Name (Spouse/Significant other): ________________________ Diver: Yes / No
Additional family members:
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Membership includes: Diver, diving or non-diving spouse and minor children under 17.
Membership Dues: $15.00 (annually, not prorated)
Membership expires each year on December 31.
All membership applicants must be approved by a majority of club members at a scheduled club meeting.
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In consideration of my (our) being admitted as a member(s) of the Michigan Underwater Divers Club, I (we) hereby release fully and forever the Michigan Underwater Divers Club, and its members, from any and all incidents or accidents which may be incurred while participating in Club activities. In addition, I (we) do hereby agree to adhere to the stipulations of the Constitution and By-laws of the Michigan Underwater Divers Club.
Date: ______________ Name: __________________________________
Signature: __________________________________________________
This is a volunteer organization and relies on our membership to donate their time in support of our various activities. Please help whenever and wherever possible.
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Club President or Authorized MUD Club Representative
Proof of diving certification reviewed: _______________
Membership Acceptance Date: ____________
Meetings are held at:
Benton Harbor Regional Airport Meet in the Lobby 1123 Territorial Rd Benton Harbor, MI – 49022
Every 3rd Tuesday of each month (except December) Starts: 7:30 p.m.
Club Contact: MuddyDiver@aol.com
Club Website: mudclub.scubaobsessed.com
Membership Request Form
