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MARKER BUOY DIVE CLUB ADVANCED CERTIFICATION REIMBURSEMENT REQUEST



TERMS AND CONDITIONS

The club will reimburse members $25.00 for successful completion of advanced certification courses that increase the member’s competency and safety for diving. There is a limit of 3 reimbursements per club member per calendar year (January to December). Courses that qualify are advanced scuba training courses from an accredited provider agency and also include, O2 Provider, and initial First Aid, CPR and AED provider (not renewals). Reimbursement for other courses is subject to board approval. Showing proof of course completion to the Treasurer is required for reimbursement. The date of course completion must be later than the date you joined the Club and reimbursement must be requested within 3 months of course completion.


First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
Parent or Guardian's Email Address

Email*

Confirm Email*
Upload Proof of Course Completion
  
Please upload proof of completion. This can be a copy of your certification card or a screen shot showing course completion. *
Valid file types: JPG, GIF, PNG, and PDF
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 Course Information

Course Name including Agency *

Date Completed *
How would you like to receive your reimbursement?*
Send it to me using Paypal. If yes complete email address field. Payment will be sent to this email address.
Send me a check. If yes complete mailing address field

Email Address

Mailing Address
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.


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