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: ___________
date: ___________

# of night dives: _______________

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:
______________________________________

Last dive

Gain more confidence, learn new skills and receive topnotch instruction by taking one of our courses or
specialties!

Signature: __________________________________________________
_________________________

Date:

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