John Rumney - Marine Encounters Scuba Diving Cairns Port Douglas Coral Sea and Great Barrier Reef

DIVER / SNORKELER PROFILE FORM

Trip Details

Departure Date

Return Date

Passenger Details

Name		Date of Birth
Permanent Address		City
State		Post Code
Country		Gender	Male Female
Phone		Email
Weight	For Flights	Height	For Flights

Dive Qualifications & Experience

Snorkeler Only	(If Snorkeler Only - Skip the Dive Qualifications and Experience questions below)
Certification Agency		Certification No		Certification Level: (Open Water/Advanced etc)
Number of dives		Date of last dive
Nitrox Certification Level (if applicable)		Nitrox Certification Agency (if applicable e.g TDI, PADI)

Other Information
Do you have any special dietary requirements? (allergies, vegetarian. etc)	Details:
Do you have any medical conditions (such as epilepsy/asthma/diabetes/decompression sickness /allergies, etc) that are relevant to diving, that we should be aware of?	YES NO If yes please provide details: If �yes� we require a letter from a Doctor trained in diving medicine stating that you are fit to scuba dive with your condition.

Emergency Contact
Name:		Relationship:		Email:
Address				Phone:

Dive/Snorkel Requirements


Please Note: The Great Barrier Reef Marine Park Authority collects an environmental management charge of $16.50 per visitor to the Marine Park and in some cases fuel and port levies apply.


I have Diving insurance?
Insurance Membership No.		Insurance Organisation:		Insurance Contact Phone:

� Eye to Eye Marine Encounters