Bimini Trip Application
Please fill out this application, put down your deposit and someone from our team will get back to you in 48 hours to let you know if your application has been accepted!
First Name
*
Last Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Nationality
*
Passport Number
*
Health Insurance Provider
*
Insurance Provider Contact Number
*
Insurance Policy Number
*
Relevant Medical Issues
*
Are you Covid vaccinated?
*
Yes
No
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Dietary Restrictions
*
Additional requests / relevant info (e.g. special occasions etc)
*
Why do you want to come on this trip?
*
*
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Bimini Dolphin Trip Deposit
$
1,200.00
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
Submit
Should be Empty: