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: _________________________________