Membership Application Form

To join us, please print and mail this completed Application form,
along with a completed Release Form / Forms with your check to:
(  Fill out one Application for each diver in the Family )
  MAIL OR BRING TO A MEETING  Print Release Form Click Here

The Sacramento SeaHorse Treasure, Tom Moorse
6749 Walnut Ave
Orangevale, Ca  95662

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Membership: $25.00/yr.  per family

Name: ______________________________ Date: _____________

Address: _________________________________

City: ___________________________ State: ______ Zip:________

Home Phone: ( __ )  ____- _____

Work Phone:  ( __ ) ____- _____

Cell Phone:     ( __ ) ____ - _____  

E-mail: ________________________________________________________________

Certification Number: ________________ Level: ____________

Agency: PADI    NAUI     Other: ________________________________

Certification Date: ____/___/____

Birthday  (M/D) :   ___  / ___

Two Emergency contacts,  Names and
Phone Numbers:( 1 )_______________________(     ) ___ - ___________

                            ( 2 )_______________________(     ) ___  -  __________

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