Loading...

Marker Buoy Dive Club Dive Host Air Card Request Form

Notes-

To qualify for an air card there must be at least six club members attending (nonmembers or guests do not count). Cards are mailed to the host by the treasurer. Please allow 7 days for delivery. 

The Club has preferred shops for air cards. We ask that you select one of those shops because we get a discount on our card purchases. If you want a card from another dive shop you will need to purchase the air card and submit a receipt for reimbursement. Receipts should be emailed to treasurer@markerbuoydiveclub.org and should include the dive date and site. The Club pays for air cards only. No reimbursement for Nitrox cards. 

Today's date: December 13, 2024

First Dive Host Name

First Name*

Last Name*
First Dive Host Age Acknowledgment*
First Dive Host Date of Birth*
I certify that I am 18 years of age or older
First Dive Host Signature*
Second Dive Host Name

First Name*

Last Name*
Second Dive Host Date of Birth*
Third Dive Host Name

First Name*

Last Name*
Third Dive Host Date of Birth*
Fourth Dive Host Name

First Name*

Last Name*
Fourth Dive Host Date of Birth*
Fifth Dive Host Name

First Name*

Last Name*
Fifth Dive Host Date of Birth*
Sixth Dive Host Name

First Name*

Last Name*
Sixth Dive Host Date of Birth*
Seventh Dive Host Name

First Name*

Last Name*
Seventh Dive Host Date of Birth*
Eighth Dive Host Name

First Name*

Last Name*
Eighth Dive Host Date of Birth*
Ninth Dive Host Name

First Name*

Last Name*
Ninth Dive Host Date of Birth*
Tenth Dive Host Name

First Name*

Last Name*
Tenth Dive Host Date of Birth*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Additional Information

Dive Date *

Dive Host

Dive Location *
Was the dive on the Club Meetup Calendar and posted at least 7 days before the event? *
Yes
No
Are you the person who originally posted the dive to the Club Meetup calendar? *
Yes
No

Number Attending *
Dive Shop for Card*
  
Attach receipt if other dive shop is chosen
Valid file types: JPG, GIF, PNG, and PDF
Reimbursement Options*
Paypal- Preferred- We will use the email address on this form to send payment
Mail me a check
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!