Group Tour Application and Diver InformationPlease complete this document, as well as the Waiver. Return both to Island Dreams.► Important: Please also send us a photostatic copy of the photo page of your passport.
Name: ___________________________________ Destination: ______________________________
E-mail address: ____________________________ Trip Dates: ______________________________
Mailing address: ____________________________________________________________________
City, State, & Zip Code: ______________________________________________________________
Home Phone: _____________________________ Business Phone: ___________________________
Occupation: ______________________________ Company: _______________________________
Passport Number: __________________________ Date & Place of Issue: ______________________Note: Your passport should remain valid for six months following your scheduled departure date from the foreign country.
Please indicate who should be notified in the event of a medical emergency:
Name: ___________________________________ Relationship: _____________________________
Your Physician: ____________________________ Phone: __________________________________
What medications are you taking? ______________________________________________________
For what conditions are you taking medication? ____________________________________________
Do you have any medical conditions that contra-indicate scuba diving? _________________________
Do you have any special dietary requirements? ____________________________________________
SCUBA Diving Experience
Year of Certification: _________________ Agency (PADI, NAUI, etc.): ______________________
Certification Level: ___________________ Certification Card Number: _______________________
How many dives have you made? _______ Date/Place of most recent dive? ____________________
How do you rate yourself as a diver? Beginner ____ Average ____ Advanced ____ Expert ____
Have you had Lifesaving Training? ________ CPR Training? ________ Medical Training ________
To the best of your knowledge, have you ever suffered decompression sickness? _________________
Where have you been diving in the Caribbean? ____________________________________________
Where have you been diving in the Pacific? _______________________________________________
The undersigned certifies that this information is correct, and that he/she is a properly trainedand certified scuba diver, capable of safely participating in scuba diving activities. Theundersigned agrees to personally accept responsibility for his/her own actions, personal liabilityand well being, and to abide by Island Dreams “Terms & Conditions.”
SIGNATURE: _________________________________