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Roatan Waiver Form 1

Roatan Waiver Form 1

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Published by Susanne Rudek

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Published by: Susanne Rudek on May 04, 2010
Copyright:Attribution Non-commercial

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05/04/2010

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Personal Information
Name: ___________________________________________________________________________________ Date of Birth: ___________________________ Where are you staying on Roatan?: __________________ Mailing Address: ___________________________________________________________________________  _________________________________________________________________________________________ Email: __________________________________Telephone #: ____________________________________ 
Emergency Contact Information
Name: __________________________________Relationship: ____________________________________ Email: ___________________________________Telephone Number: _______________________________ 
Diving Information
Number of previous dives: ___________ # of night dives: _______________Last divedate: ___________ Certifying Agency:__________________________Certification Number: _____________________________ What level diver are you (include any specialties you have obtained)?: ________________________________ Dive Insurance Information: __________________________________________________________________ Name of dive club or dive shop you are affiliated with at home: ______________________________________ 

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