Initial Travel Form

Traveler Details:

All information is encrypted, they don't harvest and we don't sell.
Full Name as it appears on passport

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Personal Information:
Date of Birth DOB*
Passport Number Pass Number*
Citizenship On passport*
Expiration Date PP Expire Date*
I am a certified diver
Certification Agency blanks
Certification Level Level on cert card
Certification Number On passport
Are you a Nitrox Diver?
Nitrox Certification Number blanks
Nitrox Certification Agency On passport
Date of last dive

MonthDayYear
How many dives do you have?
Location of your last dive?
Please list any special requirements you may need:
In case of an emergency, please notify Emergency Name* (someone not on this trip).
Phone number of contact* Emergency Phone*.
Dietary allergies or preferences* Allergies/Preferences
Other room/meal requests* Requests
*Please note, we will make every effort to accommodate your requests, but cannot guarantee them. I will let you know in advance if they can't accommodate.
I have been advised to purchase DAN travel protection and dive insurance * while traveling with Aquatic Escapes Dive Center, LLC. (We will happily guide you through this.) I understand if I choose not to purchase the insurance:

1) All medical bills have to be paid in full at the destination before I am allowed to travel home (foreign hospitals don't accept any of our health insurance). Initial to Acknowledge* The destination hospital/doctor will expect you to pay the hospital bill in full and submit to your insurance agency when you arrive home. DAN insurance pays the bill instantly and is honored in any country or destination.

2) I realize my entire vacation will be non-refundable, non-transferrable and can't be changed, no matter what the circumstance Initial to Acknowledge*.

3) Should I have to change or cancel my trip, it is my responsibility to pay Aquatic Escapes Dive Center, LLC any unpaid balance along with change/cancellation fees (per resort) within 15 days of cancellation Initial to Acknowledge*.

*DIVERS ALERT NETWORK (DAN) insurance is highly recommended (required for most trips). They will cover all of the above, allowing you the best medical care and reliability you can count on. They are easy to deal with and the only one we can stand behind.
Please sign indicating you understand the terms of travel and all the information above is correct.
Thank you for taking the time to fill out this form.

We will be in touch with you shortly to confirm receipt.
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Traveler Details:

Personal Information:

Thank you for taking the time to fill out this form.