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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.

Are you a Certified 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:
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