Download Printable Registration Form (PDF)
Diving For Life

Diving For Life 2012 Bali Jamboree
REGISTRATION FORM


- October 13-20, 2012
- Only one person per application
Step 1: Complete Registration Form online and submit.    
Step 2: Print the completed Form & Waiver (generated automatically), sign it, and mail WITH your deposit check. Credit cards CANNOT be used for the deposit. Unsigned forms or forms received without deposit checks will not be processed.
Step 3: Mail check (make check payable to Diving for Life - U.S. funds only) & copy of signed Registration Form to:
Ed Pon - Diving For Life - 2 Columbus Avenue, #15D - NY, NY 10023
Please use REGULAR 1st CLASS MAIL; No Fed Ex, UPS or Airborne accepted
For International Participants email a copy of Pay Pal payment receipt & copy of signed Waiver to: dfl2012@divingforlife.org.
Participant Name
    First Name:    M.I.:    Last Name:

Mailing Address
    Street:    City:    State/Prov:    Zip/PC:    Country:

Contact Information
    Email:    Phone:    Alt Phone:

Emergency Contact
    Contact Name:    Phone:     Relationship:


Diver Equipment (tanks, weights, belt included)
    I need to rent the following:
    Regulator/Gauges
    Computer
    BCD:     S    M    L    XL    XXL   
    Wetsuit: S    M    L    XL    XXL   
     I will need lbs of weight.

    I have all of my own equipment
   LGBT Scuba Club Affiliation
Club affiliation determines where your share of the DFL charity distribution goes
VDC New York
OLSSC Dallas
Sea Squirts NC
Lambda DC
TRRR Toronto
SUBS Australia 		NCRD San Francisco
Ruby Red Flippers Portland
Bottom Dwellers Seattle
Triangle New England
GLUG London
SDRSC San Diego
Non-Affiliated


Accomodations - Includes room, meal package, transfers, tips, and diving (if applicable.) IMPORTANT: Please read room descriptions carefully BEFORE making your selection - Trip Info.

  Double Occupancies (per person) Divers (per person) Non-Divers (per person)
  • Superior: wait list only wait list only
  • Garden (roommate share only): wait list only wait list only
  • Junior Suite: wait list only wait list only
  • Ocean View: wait list only wait list only
 
  Single Occupancy Divers (per person) Non-Divers (per person)
  • Superior: wait list only wait list only
  • Junior Suite: wait list only wait list only

Total: - Deposit: * = Balance Due: ‡

* Minimum deposit of US $500 due via check or money order is payable to DIVING FOR LIFE. You may pay the full amount or any amount between $500 and the full amount if you desire. Please fill in your deposit amount above so that we figure your balance currectly. Balance due by June 15, 2012; also payable by check or money order (PREFERRED METHOD).
‡ International participants may use Pay Pal for the deposit payment in the amount of $500. Balance Due may also be paid on Pay Pal. The balance due must be paid by June 15, 2012. Please note that there is a 2.2% per transaction surcharge when using Pay Pal. Be sure the account doesn't expire before November 2012. Please see the cancellation policy below.

I am an international participant and would like to pay with PayPal.

PayPal Total: - PayPal Deposit: * = PayPal Balance Due: ‡

Roomate Questionnaire
    I will be sharing a room with:
    I prefer: one bed     two beds    

    If your roommate has not been selected, please answer the following to help us match you best:
    Gender Preference: female only     prefer female     male only     prefer male
    I am a: non-smoker     smoker     snorer     non-snorer
   

T-Shirt Size: Small     Medium     Large     XL     2XL     3XL