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Atlantic Rangers Scuba Club Membership Application
Thank you for using this form to apply for ATRA membership.
Annual dues are
$50
(
Associate Members
) and
$75
(
Full Members
). Note: Full membership must first be approved.
Dues are payable
January each year
, via PayPal by going to
http://paypal.me/AtlanticRangers
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Today's Date
*
MM
/
DD
/
YYYY
Last Name
*
Your answer
First Name
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State (two letter abbreviation)
*
Your answer
Zip Code
*
Your answer
Home Phone (XXX) XXX-XXXX
*
Your answer
Mobile Phone (XXX) XXX-XXXX
*
Your answer
Is it okay to contact you via SMS/Text?
*
Yes
No
Email Address
*
Your answer
Date of Birth (XX/XX/XXXX, year optional)
*
Your answer
Highest Certification Level (select one)
*
Not certified
Open Water
Advanced Open Water
Rescue
Dive Master
Assistant Instructor
Instructor
Course Director
Specialty Certifications (select all that apply)
*
Nitrox
Peak Performance Buoyancy
Master Diver
Wreck
Deep Diver
Dry Suit
Other:
Required
Diving Certification Agency (if applicable)
Your answer
Dive Insurance Agency
*
I do not have dive insurance
DAN
Other:
Dive Insurance ID Number (if applicable)
Your answer
How did you hear about ATRA?
*
Your answer
What skills or experience do you have that are relevant to ATRA's mission?
Your answer
Where would you like to see the club travel for a future dive trip?
Your answer
What is your main interest in joining ATRA?
Your answer
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