UHEXSO

The Undersea Heritage & Exploration Society
MEMBERSHIP APPLICATION FORM

Thank you for your interest in the Undersea Heritage & Exploration Society. There are many opportunities within UHEXSO and we are sure that you will be able to find a level of participation that is both rewarding and enriching to you. To become a member, please complete the following form and mail the original to:

UHEXSO
c/o John F. Hoover
5624 Lomita Verde Circle
Austin, Texas 78749-4200

If you have any questions, feel free to contact John Hoover at: UHEXSO@airmail.net

If you getting this application from the UHEXSO web site, you can click on the print function to obtain a copy.

I. Membership Application (please print or type)

Name:_____________________________________________________________________________

Address:___________________________________________________________________________

City/State/Zip:_______________________________________________________________________

Contact Numbers: Home Phone:__________________________________________________________

Work Phone:________________________________________________________________________

Pager:_____________________________________________________________________________

Fax:_______________________________________________________________________________

E-Mail_____________________________________________________________________________

Diver Certification Level:________________________________________________________________

Agency:_____________________________________________________________________________

Medical Coverage Carrier:_______________________________________________________________

Policy/Group Number:__________________________________________________________________

Emergency Contact Information:

Person to Contact:______________________________ Relationship to You:_____________________

Work Phone:______________________ Home Phone:______________________________________

UHEXSO sponsors the following activities. Please rank the activities from 1 to 3 in order of preference, with 1 being the activity in which you are most interested in participating.

__________ dive rallies

__________ archeology expeditions

__________ collection of historical diving equipment

Indicate the level at which you plan to join UHEXSO. Initial membership dues should be enclosed with the membership application. Subsequent dues will be due on February 14th of each year. Make checks payable to UHEXSO. At this time UHEXSO accepts only personal or cashiers checks and money orders for payment of dues. Do not send cash or currency. Payment is only in U.S. dollars. Thank you.

_________Corporate Member-$50(goods, services or funds)

_________Family Member-$25

_________Individual Member-$20

_________Student/Military-$15

II. Release of Liability and Hold Harmless Agreement

Please be advised that by signing this section you agree to release your rights to sue or otherwise file claims against The Undersea Heritage & Exploration Society (UHEXSO); any of its members, officers, directors, trustees, advisors or volunteers; and/or any company, individual, governmental agency, foundation or organization that in any way supports, aides or lends equipment or financial aide to UHEXSO.

SCUBA and surface-supplied diving, marine archeology projects and expeditions, and military re-enactments are potentially hazardous practices. If practiced or conducted incorrectly or with inadequate planning, procedures, understanding, or training, they can expose a person to considerable risks including serious injury or death. Specialized training, equipment and experience are necessary to safely participate in diving, marine archeology, and military re-enactments. Membership in UHEXSO and/or any other organization contained or formed under the UHEXSO corporate umbrella is not intended as a substitute for proper training, knowledge, and skill. No individual should abandon common sense in pursuit of these activities beyond his or her abilities.

Those who participate in UHEXSO activities as members, guests or advisors do so at their own risk and take responsibility for their own actions while participating in these events. All the elements of hazard and risk associated with diving, marine archeology, and re-enactments cannot be brought out within the scope of UHEXSO training, memoranda, text and discussions. Therefore the individuals, members, advisors, trustees, officers and directors of UHEXSO, along with any and all companies, governmental agencies, contractors, organizations, clubs and individuals who contribute, donate, sell or lease equipment or provide any such service, advice, product or financial support used by UHEXSO shall not be held liable for any personal injury, financial or property damage or injury including death which may result from any form of participation by you, your family, or your guests in the aforementioned activities.

I have read and do understand the above UHEXSO Release of Liability. I understand and accept the risks involved in participating in these activities and accept responsibility for family members and/or guests that I may bring to these activities. This Disclaimer shall be in effect at all times unless written notice of termination of this agreement is provided by either party within thirty days (30) prior to participation in any event or activity sponsored, conducted or participated in by the above named individual or UHEXSO.

Printed Name:_______________________________________________________

Signature:____________________________________ Dated:_________________

III. Model Release

I hereby give permission to allow my visual and audio image and likeness to be used in all possible media forms by those authorized by the Undersea Heritage & Exploration Society (UHEXSO) to film, record and photograph any event in which I participate with UHEXSO. I give my permission in this regard in perpetuity and with the understanding that no compensation for use of said images will be paid, nor shall approval for the use of said images be required or obtained from the undersigned, their heirs, executors, administrators or assigns.

Printed Name:____________________________________________________

Signed:___________________________________ Dated:_________________

UHEXSO Use Only:

Date Received:_______________________________

E-Mail Address Confirmed and Entered:___________

Certificate Mailed:____________________________

Special Contact Instructions Needed:______________

__________________________________________

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