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Membership Registration

Thank you for your interest in becoming a Roddenberry Dive Team Member. As a Member, you will receive notifications of upcoming events as well as discount and promotions on gear, dive trips and other activities. Your support and participation is greatly appreciated.

To become a member, please fill out the below form in it's entirety. If you are not a scuba diver, please disregard the section in Yellow.

IMPORTANT: Each member must Print, Fill-Out, Sign and Mail a liability release waiver before we can activate your membership. We require this form be completed EVERY YEAR. Please go to our Liability Release page to download the waiver.

Liability Release

Are you a Certified Diver?	Yes No
Are you interested in becoming a Certified Scuba Diver?	Yes No
Last Name:
First Name:
Mailing Address:
Address 2:
City:
State/Province:
ZIP/Postal Code:
Country (if not USA):
Phone Number:
Cell Number:
Your Email:
Date of Birth:	(mm/dd/yyyy)
	*Due to the Children's Online Privacy Protection Act, Individuals 13 and under are not permitted to become Roddenberry Dive Team Members. However, they can take part in age appropriate non-dive related activities and event. A parent or legal guardian must accompany the underaged individual at all times.
Marital Status:	Married Single
Sex:	M F

Security:	Enter the above code. Ignore case and spaces.

For Certified Divers Only:
Certifying Agency:
Level of Certification:
Date Certified:
Additional Specialty Certifications:
Total Number of Dives:
Emergency Contact:
Emergency Contact Phone:
Please download and complete our Liability Release