Application for Buffalo Aqua Club membership

NAME:

STREET:

CITY, STATE, ZIP:

PHONE NUMBER:

E-MAIL ADDRESS (for Club use only):

DATE OF BIRTH:

LEVEL OF CERTIFICATION: CERTIFYING AGENCY:

YEARS DIVING: NUMBER OF DIVES:

EMERGENCY CONTACT NAME:

EMERGENCY CONTACT PHONE:

I (print your name), _______________________ acknowledge that scuba diving involves inherent risks and understand and agree that the Buffalo Aqua Club, its officers and members accept NO liability for any and all accidents and/or injuries incurred by a member. I agree to dive safely, within my limitations, and with my own discretion. I agree to abide by the Buffalo Aqua Club bylaws and understand that any violation can and shall be cause for my dismissal. I am a certified diver and do not have health and/or medical conditions that pose a risk to myself or others when scuba diving, and agree to avoid diving if and when they arise.

Signature: _____________________________________ Date: ___________________

Sponsor member (optional): _______________________________

Please attach a photocopy of your certification card(s) (C-card) and DAN (Divers Alert Network) card (if a member), along with a check for the dues, and mail to:

Buffalo Aqua Club
P.O. Box 176
West Seneca, NY 14224