Membership Application - Charles County Dive Rescue

Contact Active911 Professional Certifications References Authorization

1. Contact & Identity

Full Name *

Date of Birth *

Sex *

Email (Primary Contact) *

Mailing Address *

Phone Number *

Driver's License or State ID Number *

This is required for our background check and is stored securely.

2. Active911 Setup

Phone Operating System *

Do you have Active Alert downloaded? *

Yes No

Active Alert Device Code

Have you ever been convicted of a crime or felony (including DUI/DWI)? *

Yes No

Full conviction details

3. Professional & Military History

Employer Name

Job Title

Military Service

Yes No

Highest Rank

Date of Service

Discharge Type

Emergency Services Affiliations (Past/Present)

4. Certifications & Goals

Other Certifications (Non-Diving)

Are you a diver?

Yes No

Diver Certification Agency

Date Certified

Highest Rating

Specialty Dive Training

Summary of Dive Experience

Why do you want to be a member and what are your goals? *

5. Emergency Contact & References

Emergency Contact

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

References

Please provide up to three professional or personal references.

Reference 1 Name *

Reference 1 Phone *

Reference 2 Name

Reference 2 Phone

Reference 3 Name

Reference 3 Phone

Were you referred by a current team member? If yes, who?

6. Authorization & Release

I, the undersigned applicant, certify that all information provided in this application is true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts is cause for rejection or dismissal.

By checking the box below, I authorize Charles County Dive Rescue to use the information provided internally for the purpose of evaluating my candidacy for membership, including conducting a background check and contacting the references I have provided.

I release Charles County Dive Rescue from any liability arising from the use of this information in accordance with this authorization.

I have read, understand, and agree to the above Authorization and Release.

Digital Signature (Type Full Name) *

Typing your name here serves as your legally binding digital signature.

Verify Your Email

We've sent a 6-digit verification code to your email address.

Resend Code

Application Submitted!

Thank you, Applicant.

Your membership application has been successfully submitted to Charles County Dive Rescue.

What Happens Next?

You will receive a confirmation email shortly. This email will contain details about the next steps in the application process.

Please check your spam folder if the email doesn't arrive within a few minutes.

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