MEMBER APPLICATION / PROFILE
Last name:           First name:        
Street address:                  
City       State:     Zip:        
Phone:   (             )   --   2nd Phone: (             )           --  
E-mail:                      
Emergency contact         Phone: (             )           --  
Certification level:         Date of certification:      
How often do you dive per year?       Number of logged dives:  
Diving preferences (Check all that apply):
  Phototography/videography   Lobster   Wreck
  Night   Spear fish   Drift
  Nitrox   Boat   Cave/cavern
  Deep   Shore   (other)  
Primary reason for joining a dive club:
  Meet new divers   Social functions
  New dive sites   Discounted diving
  Education   (other)          
List Florida dive destinations that you would like to dive:
                       
                       
List non-Florida dive destinations that you would like to dive:
                       
                       
List social activities you would like to see the dive club organize:
                       
                       
List diving/environmental topics you would like to learn more about:
                       
                       
How did you hear about the Jupiter Drift Divers?
                       
Would you be willing to serve on a planning committee? YES NO
Signature:             Date