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Laurel Divers Membership Application

ANNUAL DUES are $40 for head of household, $30 for next family member, and $24 for each additional member. Additional members must reside at the same address. Dues will be prorated quarterly for new members.


Once you have submitted your application please submit your payment for dues with one of the options listed further in the application. You may also send cash/check via mail to Frank using the address below, please be sure to include the name of the applicant(s) if it is not already on the check. 


Please note that your application will not be approved until dues are paid and the application will be rejected after 30 days for non-payment.

Mailing Address:

Laurel Divers

c/o Frank Dougherty

129 E Doris Ave

State College, PA 16803

Frank@laureldivers.com



Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Please fill out the below information for the participant.
Level of certification*
Certification Agency*

If other: please specify

Where were you certified? *

Who was your instructor?
Are any other members of your household members of Laurel divers?*

Tell us a little about your diving experience: *

Goals in diving:

Tell us a little about yourself (ex: what do you do for a living? Any skills/hobbies?): *
How did you hear about the Laurel Divers?*

if Other/member: who/where?

Do you know any current LD members? Or did someone refer you to us?
How do you intend to pay your dues? *
Cash/check by mail
PayPal
In person at a monthly meeting

PayPal

Frank@laureldivers.com

Mailing address for dues

Laurel Divers

c/o Frank Dougherty

129 E Doris Ave

State College, PA 16803

Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Participant's 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:*
This section only needs to be completed if the participant is a minor.

We no longer require a notarized signature for minors to participate. However certain steps need to be taken to prove that the minor does, in fact, have parent/guardian permission to participate in diving and other club activities. Please upload a current photo below that includes yourself AND the minor in the same photo.

  
Photo with parent/guardian AND minor
Valid file types: JPG, GIF, PNG, and PDF
ACKNOWLEDGEMENT and RELEASE

 

By submitting this application on this date of application (listed above) the undersigned hereby acknowledges the dangers involved in the sport of SCUBA and avows having attained a national certification in said sport. Further, it is acknowledged that the participant and/or guardian of the participant (listed above) hereby agrees to release and hold harmless the Laurel Divers and its officers from any and all damages of whatever nature might be incurred by the participant or any other party as a result of their involvement in said activities, and further, to hold Laurel Divers and its officers harmless from any and all damages and costs incurred by it, including but not limited to: reasonable attorney's fees, as the result of any demands, suits, costs, judgements, and/or verdicts resulting from claims made concerning involvement in said activities. The activities stated above shall include but not be limited to dives, dive trips, meetings, picnics, cook-outs, parties, social events, etc. sponsored, organized, or supported by the Laurel Divers and/or their representatives.

IN WITNESS THEREOF, intending to be legally bound, I/WE have hereunto set my/our hand and seal. 

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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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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