Sign Up for a One Day Trip on Ustica Island

Client Registration Form

Scuba Diving or Snorkelling Experiences on Ustica island
Client Name*

First NameLast Name
Place of birth*
Birth Date*

DayMonthYear
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Mobile Number*

Area CodePhone Number
Date*

DayMonthYear
When are you arriving in Ustica?
Certified DiverBeginnerSnorkellerPassenger on Board
PADIWebsiteReferralGoogle SearchOther
2-Tank Guided Dive Day [starting from €114]Discover Scuba Diving Program (Equipment Included) [€120 - €160]Snorkelling Tour [€ 50]Only Boat Ride [€25]
€ 0,00 - Snorkelling Kit (mask, snorkel, fins)€ 5,00 - 3mm Wetsuit for Snorkelling€ 20,00 - Full Equipment (Scuba Unit & Personal Gear)€ 5,00 - Nitrox (2 dives/Ean30)€ 5,00 - Short Term Dive InsuranceOther
Add a PADI Specialty Diver Certification
The price is for the PADI eLearning you will get.
If you are a Certified Diver, please provide your dive licence info:
Level
OWD, ADV, etc.
Agency
PADI, SSI, etc.
Certification Date
Student n.
on your card
Logged Dives
Aprox.
last Dive

MonthDayYear
When was it?
Additional Comments
Height
Weight
Foot Size
Signature

Legible signature, thanks!
Should be Empty:

Client Registration Form