Membership Application – Piedmont Diving and Rescue Association

Membership Selection Type*

Please select a Membership Type

New Member (Non Instructor)

Price:

Renewal (Non Instructor)

Price:

New Member (Instructor)

Price:

Renewal (Instructor)

Price:

Diving Student Training Pass

Price:

Please Note: This membership is only valid for students looking to take their Open Water Certification. No card and key will be issued for this membership type.

Upgrade Student Pass to Regular Member

Price:

Please Note: This membership is for students that have earned their Open Water Certification within the past year and would like to become full PDRA members. Once registered a card and key will be issued.

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Name of Instructor and/or Dive Shop*

Note: If you are applying for a Diving Student Training Pass, you must list the name of your instructor and/or the dive shop through which you are taking your classes.

Name of Instructor and/or Dive Shop*

Note: If you are applying for a Diving Student Training Pass, you must list the name of your instructor and/or the dive shop through which you are taking your classes.

Instructing Quarry Selection*

Please select which quarry you will be instructing at most often.

New Member Quarry Selection*

Please select which quarry you will be diving at most often

Upgrade Member Quarry Selection*

Please select which quarry you will be diving at most often

Upgrade Member Quarry Selection*

Please select which quarry you will be diving at most often

Instructor Committe Member American Quarry*

Please select which Instructor Committee Member you interviewed with.

Instructor Committe Member JMR Quarry*

Please select which Instructor Committee Member you interviewed with

Instructor Committe Member Lake Norman Quarry*

Please select which Instructor Committee Member you interviewed with

New Instructor Proof of Insurance*

Note: PDRA Rules requires that all members who are applying as instructors must complete all information found in the "New Instructor Information Packet". PDRA-approved instructors must provide proof of insurance and show that PDRA is listed as an "additional insured" before being issued a card and key. Please upload a PDF copy of your proof of insurance here. If you are listed on the policy of a Dive shop, you must provide a copy of the proof of insurance where you are listed as being insured. If you are applying as a new instructor you will be contacted by a PDRA representative to start the interview process.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 64 MB.

Instructor Proof of Insurance Instuctor Renewal*

Note: PDRA Rules requires that all members who are renewing as instructors must resubmit their proof on insurance each year. PDRA-approved instructors must provide proof of insurance and show that PDRA is listed as an "additional insured" before being issued a card and key. Please upload a PDF copy of your proof of insurance here. If you are listed on the policy of a Dive shop, you must provide a copy of the proof of insurance where you are listed as being insured.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 64 MB.

New Instructor Information Packet*

Please upload a scanned and signed copy of your New Instructor Information Packet. Note: Incomplete packets will be rejected and not approved.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 64 MB.

Instructor Certification "C" Card*

Please upload a scanned copy of your Instructor Certification "C" Card.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 64 MB.

Applicant Full Name*

First Last

Current Member Name*

First Last

Key Number

Applicant Date of Birth*

Is the Applicant under the age of 18?*

Applicant Address*

Street Address City State ZIP Code

Applicant Phone*

Applicant Email*

Family Membership

NOTE: To qualify as a family member, you must be the spouse or child of a regular member living in the same household or a child for whom the member is legally responsible. If you have any questions as to what constitutes a family member, please contact the Membership Chair. Non-diving members of a family are included in this membership at no additional cost. ALL DIVING members of the family are required to join as family members and EACH individual diving family member must sign this membership application and the statement of understanding. If said diver is under the age of (18) years said separate application and statement of understanding must be signed by both the diver and the parent and/or guardian; whichever is applicable. Further, any family member becoming a certified diver subsequent to Family Membership application and/or renewal must submit a separate application and statement of understanding within 30 days of certification. The following are the names, birthdates, relationships, and diving affiliation of each family member covered under the above mentioned Family Membership.

Please note how many family members (IN ADDITION TO MEMBER NAMED ABOVE) need membership ($20/family member)*

Name (Family Member #1)*

First Last

Age (Family Member #1)*

Relationship (Family Member #1)*

Diver (Family Member #1)*

Yes
No

Diver 1 Membership

Price:

Non-Diver 1 Membership

Price:

Name (Family Member #2)*

First Last

Age (Family Member #2)*

Relationship (Family Member #2)*

Diver (Family Member #2)*

Yes
No

Diver 2 Membership

Price:

Non-Diver 2 Membership

Price:

Name (Family Member #3)*

First Last

Age (Family Member #3)*

Relationship (Family Member #3)*

Diver (Family Member #3)*

Yes
No

Diver 3 Membership

Price:

Non-Diver 3 Membership

Price:

Name (Family Member #4)*

First Last

Age (Family Member #4)*

Relationship (Family Member #4)*

Diver (Family Member #4)*

Yes
No

Diver 4 Membership

Price:

Non-Diver 4 Membership

Price:

Name (Family Member #5)*

First Last

Age (Family Member #5)*

Relationship (Family Member #5)*

Diver (Family Member #5)*

Yes
No

Diver 5 Membership

Price:

Non-Diver 5 Membership

Price:

Name (Family Member #6)*

First Last

Age (Family Member #6)*

Relationship (Family Member #6)*

Diver (Family Member #6)*

Yes
No

Diver 6 Membership

Price:

Non-Diver 6 Membership

Price:

Name (Family Member #7)*

First Last

Age (Family Member #7)*

Relationship (Family Member #7)*

Diver (Family Member #7)*

Yes
No

Diver 7 Membership

Price:

Non-Diver 7 Membership

Price:

Name (Family Member #8)*

First Last

Age (Family Member #8)*

Relationship (Family Member #8)*

Diver (Family Member #8)*

Yes
No

Diver 8 Membership

Price:

Non-Diver 8 Membership

Price:

To Be Completed By Applicant

In consideration of the acceptance of this application for membership in the PIEDMONT DIVING AND RESCUE ASSOCIATION, INC. I hereby for myself, heirs, executors or administrators and personal representatives and assigns, waive any and all claims and rights for damages which I now have or may hereafter in the future have against PIEDMONT DIVING AND RESCUE ASSOCIATION, INC. including all of its officers, agents, members, instructors, and affiliated clubs, for any and all injuries on any property owned by the PIEDMONT DIVING AND RESCUE ASSOCIATION, INC. and I hereby release and discharge the PIEDMONT DIVING AND RESCUE ASSOCIATION, INC., along with its officers, directors, agents, members, instructors, and affiliated clubs of and from any and all liabilities whatsoever to me, my heirs, executors or administrators, my personal representative or assigns on account of any and all liability arising out of such claims or injury. I understand membership is subject to my being a qualified SCUBA DIVER as certified by a nationally recognized SCUBA certification agency or that I am currently engaged in taking instructions from a qualified instructor of any nationally certification agency and I will dive only in his presence under his supervision. (Non-diving family members are exempt from the certification requirement but agree to all other conditions of this release and are required to abide by the By-Laws, Rules & Regulations and Code of Ethics of the PIEDMONT DIVING AND RESCUE ASSOCIATION, INC., and all the rules as set forth in the Statement of Understanding and Waiver as are the certified members.) The undersigned has read the foregoing application and rules for membership and understands same. Further, the undersigned agrees to abide by and follow said rules and regulations as stated above, and understands that a violation of these rules and/or the code of ethics may result in the revocation of my membership and other privileges.

In witness where of I hereto set my hand and seal this day of (Today's Date)*

Applicant Signature*

Signature of Parent/Guardian if under 18/Signature Family Member*

Signature Family Member*

Piedmont Diving and Rescue Association Statement of Understanding and Waiver

IN THE MATTER OF THE PIEDMONT DIVING AND RESCUE ASSOCIATION, INC. AND (LIST FULL NAME OF APPLICANT)*

First Last

As a condition of my acceptance for membership in the Piedmont Diving and Rescue Association, Inc., and/or my use of Piedmont Diving and Rescue Association, Inc. property. I subscribe, accept and acknowledge the following statement of understanding:

INHERENT HAZARDS: There are hazards in skin and scuba diving, as in all activities on or near the water, some of those hazards include, but are not limited to, drowning and air embolism and/or death. I hereby affirm that I am aware of and understand the inherent hazards of skin and scuba diving. I am adequately prepared to dive in the rock quarries owned or leased by the Piedmont Diving and Rescue Association, Inc. I am aware that I must abide by safe diving practices. At no time will I dive under the influence of alcohol or drugs or with questionable equipment or conduct any dive without (1) a buoyancy control device, (2) a submersible pressure gauge, (3) an alternate air source as a permanent and functioning part of my scuba equipment and (4) a certified buddy or dive partner. I will always have a means to monitor depth and time underwater and will make all my dives no decompression dives and will limit my maximum depth to my level of training and experience. I understand scuba diving is dangerous and can result in serious injury or death. My personal safety is my responsibility, not others’ responsibility. My certification card reflects that I have received training in scuba diving; and should I neglect to maintain my skills in scuba, I know that I should seek adequate refresher instruction to bring my skills to a level that will prepare me for safe scuba diving. I will exercise reasonable care in scuba diving, the selection of my equipment, the use of that equipment and the maintenance of that equipment. I confirm that I have been properly trained and certified to the level indicated on my certification card and same is presently current. I understand and agree that the Piedmont Diving and Rescue Association, its’ officers, agents, members, or affiliated clubs shall not be held liable in any way for any occurrence in connection with my future scuba or skin diving, which may result in injury, death, or other damages to me, my family, heirs, executors, administrators and/or assigns, as evidence by my signature affixed hereto, and in consideration of which I am being allowed membership in the Piedmont Diving and Rescue Association, Inc., and/or the use of Piedmont Diving and Rescue Association, Inc., property as the guest of a member. I hereby assume all risks connected therewith, whether foreseen or unforeseen, and I agree to save, indemnify and hold harmless said above parties from any claim by me, my family, heirs, executors, administrators and/or assigns, arising out of my participation in scuba diving or skin diving. I warrant that I am of lawful age and legally competent to sign this statement of understanding, or that my parent or legal guardian understands and agrees to all terms contained herein, as evidence by my parent’s or guardian’s signature; that I understand the terms herein are contractual and not a mere recital; and that I have signed this document as my own free act and upon my own volition. It is my intention as a member or as a guest of a member of the Piedmont Diving and Rescue Association, Inc., by this instrument, to exempt and release the above listed corporation, its’ officers, agents, members, and affiliated clubs from any and all liability whatsoever for personal injury, property damage and/or wrongful death, arising from my membership in the Piedmont Diving and Rescue Association, Inc. and/or use of PDRA’s facilities. I have fully read and understand the contents of this statement of understanding and acknowledge and same

RULES AND REGULATIONS As a member or guest of the Piedmont Diving and Rescue Association, Inc., and notwithstanding anything to the contrary, in consideration of promises made, it is agreed that the undersigned shall conform to the constitution and By-Laws of the Piedmont Diving and Rescue Association, Inc., as well as the following rules and regulations: *Keep the gate LOCKED / Take all action possible to remove trespassers / Do not lend your key to non-members. *All divers MUST be accompanied by a diving buddy equipped with substantially the same type of equipment. *Spear guns shall not be taken into or used in PDRA waters (unless officially sanctioned). *There is to be no display or discharge of FIREARMS, FIREWORKS OR DYNAMITE on the property. *Do not jump or dive from quarry walls. * VEST Rule, Swimmers & Divers must wear an operable BCD, PFD/safety device or wet suit capable of providing floatation. *All guests MUST be accompanied by a PDRA member with a release for each guest properly signed and in the member’s possession. All members are responsible for actions of their guests. No more than 10 guests per member are allowed at any time unless authorized in writing by the Board. This number does not apply to authorized instructors with classes. A non-member may be the guest of a PDRA Member two times per year. If the guest wished to return after the second visit, he or she must be a PDRA Member. *Do not remove items or parts of items put in quarries for your diving diversity. *Do not remove gravel or equipment from quarry belonging to a property owner. * ABSOLUTELY NO FISHING ON PDRA PROPERTY. PADDLE FISH ARE FEDERALLY PROTECTED. *No hunting allowed at any time. *No boats with gasoline motors permitted. Electric motors with weed guards permitted only when there are no other persons in the water. *PDRA members & guests shall take their litter, trash& garbage with them when leaving PDRA property. *Children shall be kept under strict supervision at all times for their safety and safety of others. *ABSOLUTELY NO PETS ON PDRA PROPERTY. *Keys are the property of the PDRA and shall not be duplicated. * I understand that the PDRA strives to foster a family-friendly atmosphere, and will not tolerate rudeness, hostility or aggressive behavior of any kind.

In witness where of I hereto set my hand and seal this day of (Today's Date)*

Applicant Signature*

Signature of Parent/Guardian if under 18/Signature Family Member*

Signature Family Member*

Total

$0.00