Trip Dates: 
Group:        

Personal Information
Name: 
Street: 
City:    
State:  
Zip:     
Phone:
Cell Phone:   
Work Phone:
E-mail: 

Customs Information
Will you be using a passport or birth certificate*: Passport Birth Certificate
Name as it appears on your Passport: 
Date of Birth: 

Gender: (M/F)
Passport Number  (Required): 
Country of Citizenship: 
Flight Information (Airline, Flight #, Arrival Time): 

Emergency Information
Emergency Contact: 
Street: 
City:    
State:  
Zip:     
Phone: 
Cell Phone:   
Work Phone:
Allergies (Food, Medications, Bee stings, etc.): 
Required Medications: 

Dive Experience
Present Certification Level: 
Years Scuba Diving: 
Date of  last open water dive:   
Number of Saltwater Dives:       
Number of Fresh Water Dives: 
Years Snorkeling: 
I rate my dive skill level as:  Non-Diver Beginner Intermediate Advanced

Roommate (if known):           
Special Needs (i.e. vegetarian, medical, etc.): 
Additional Offerings:            
(ie Nitrox, Marine Specialty, etc.)