Guest Profile Form :: Utopia Dive Village :: Utila, Bay Islands

*Required Fields

Contact Information

*Arrival Date:

*Departure Date:

*DOB (mm-dd-yyyy):

*First Name:

Initial:

*Last Name:

Address:

City:

State:

Zip:

*Email Address:

Phone:

Emergency Contact Information

*Full Name:

*Relationship:

Address:

City:

State:

Zip:

Email Address not used for database marketing purposes, travel and emergency only!
*Email Address:	*Phone:

General Information

*Any food allergies? Yes No If yes please list:

Please list food you dislike:

Do you like spicy foods? Yes No

Beverage Preferences:

*Any Medications taken during dates of travel?Yes No

Are you interesting in a massage? Yes No

Are you interested in any Activities & Excursions? If so please check which ones
Guided Snorkeling
Kayaking Excursion
Freshwater Cave Adventure
Day at the Cays
Whale Shark & Dolphin Excursion
Circle Island Tour
Flats Fishing
Deep Sea Fishing
Cayos Cochinos Eco Tour
Pico Bonito Rainforest Park
Mainland Zip Lining & White Water Rafting

Are you interesting in fishing? Yes No

If you will be diving with U Dive, please fill out the requested information below.

Diving Information

Certification Agency:

Level of Certification:

Date of Original Certification (mm-dd-yyyy):

Date of Last Dive (mm-dd-yyyy):

Number of Logged Dives:

Will you requre a refresher? Yes No

Do you wish to dive with 32% Enriched Air (Nitrox)? Yes No

Do you have your own primary and backup dive lights for night diving? Yes No

How much lead weight do you expect to don in saltwater (pounds/kilos)?

Do you require rental equipment? If so please list with sizes.

Do you have any special needs or requests?

Highly Recommended - Medical Insurance that covers any dive related incident. Please check with your insurance carrier to verify dive coverage prior to traveling to Honduras.

Insurance Carrier:

Insurance Number:

Utopia highly recommends a Dive Accident Poilicy.

If no medical insurance, please contact Divers Alert Network “DAN” www.diversalertnetwork.org and list Utopia Village Business # 1844224 as a reference.
Or go to the following link:http://www.diversalertnetwork.org/join/index.asp?RC=1844224

For reservations and questions please contact:
Utopia Village at (011)504-3-344-9387 or reservations@utopiautila.com

Utopia Dive Village