Ready to join Laguna Sea Dwellers!

 

Please fill in the following application form. Fields marked with a * are mandatory. If you do not wish to register online you can print out and fill our paper application and bring it to our monthly club meeting. Please see our detailed instructions.

 

email address (will be your login name)*
First name*
Middle name
Last Name*
Address: Street*
Address: City*
State*	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
Zip Code*
Cell phone*
Select dive experience*	Beginner Advanced Master Instructor
Number of dives*	0-100 100-500 500+
I want to receive the monthly newletter
I want to receive club announcements
I want to receive photo-contest information
Home phone
Alternate phone
DAN insurance # (Strongly recommended)
Date of birth*
Emergency contact*
Emergency phone number*
Certification agency*
Certification number
Certifcation date*
Certification Level
Non-DAN insurance info
Member Type	Individual Family Out of Area
Create a password*
Enter the code above

 

 

Thank you for your interest in Laguna Sea Dwellers! Come join us, you won't regret it!

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The Laguna Sea Dwellers is a 501(c)(7) non profit incorporated organization for people interested in scuba diving.
Laguna Sea Dwellers Dive Club
220 Newport Center Drive #11-182
Newport Beach, CA-92660
USA