Bay Area Bottom Timers
Membership Application

Member Since: ______________ .............................. .................................................................
Membership Plan (Family/Single) ($25.00/$20.00) Dues Paid: $_________

CONFIDENTIAL PERSONAL INFORMATION:
Name: _________________________________ DOB: ___________________________
Address: _______________________________ Phone: (H) ________________________
City: __________________________________ Phone: (W) _______________________
Zip: ___________________________________ Email: ___________________________
FAMILY INFORMATION: (Family Membership Only)..........
Spouse's Name: __________________________ DOB: ___________________________
Child's Name: ____________________________ DOB: ___________________________
Child's Name: ____________________________ DOB: ___________________________
Child's Name: ____________________________ DOB: ___________________________
Child's Name: ____________________________ DOB: ___________________________

DIVING BACKGROUND:................................................
Certification Agency: _______________________ Card Number: _____________________
Date Certified: ___________________________ Approx Number of Dives: ____________
Current Rating: ___________________________ Medic First Aid Certified Date: ________
O2 Provider Certification Date: ________

SPECIALTY RATINGS THAT YOU HAVE: (Circle all that apply)...............................................................

ALTITUDE, BOAT, CAVERN, DEEP, DRY SUIT, DRIFT, ENRICHED AIR, EQUIPMENT SPECIALIST, ICE,

MULTI-LEVEL, NAVIGATION, NATURALIST, NIGHT, PEAK BUOYANCE, PHOTOGRAPHER, SEARCH &

RECOVERY, STRESS & RESCUE, VIDEOGRAPHER, WRECK.

DIVING INTERESTS: (Circle those that interest you)

ALTITUDE, BOAT, CAVERN, DEEP, DRY SUIT, DRIFT, ENRICHED AIR, EQUIPMENT SPECIALIST, ICE,

MULTI-LEVEL, NAVIGATION, NATURALIST, NIGHT, PEAK BUOYANCE, PHOTOGRAPHER, SEARCH &

RECOVERY, STRESS & RESCUE, VIDEOGRAPHER, WRECK, MEDIC FIRST AID, O2 PROVIDER.

EMERGENCY CONTACT INFORMATION: ......................
Name: _______________________________ Relationship: _______________________
Phone Number: ________________________
Doctor Name: _________________________ Med. Ins. Co.: ______________________
DAN Member No.: _____________________ Med. Ins. No.: _____________________

SIGNATURE: ________________________________ ...... ............................ DATE: ________________

Please Fill Out and Return to the next meeting or mail to: BABT , P.O. Box 95, Fremont, CA 94537