Membership Type

Multiple Choice

Individual ($21.50)
Individual
Family ($31.50)
Family

Family Member Names (if Any)

Total

$21.50

Member Information

You are required to be a certified diver to dive with our organization

Are you a Certified Diver?

Yes
Yes
No
No

Last Certification - cert or course

Certification Agency

Name

Phone Number

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Address

Date of Birth

Emergency Contact

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Join the Diving Rebels' Text and Email List

Billing Information

Name

Credit Card

Visa
Mastercard
American Express
Discover

Address

Mobile Phone Number

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Diving Rebels SCUBA Diving Club

Membership Form

Founded 1958

Membership Type

Member Information

You are required to be a certified diver to dive with our organization

Emergency Contact

Billing Information