Guest Profile Form

  
 

We just need some information about you so we can make sure you have a safe and memorable trip with us.

*Required Fields

Guest Profile Information
 
First Name * Last Name *
 Email (we will keep your email private) *
 
 Address *
 
 
City * State * Zip *
   
 Arrival Date (mm/dd/yyyy) *
 
 Departure Date (mm/dd/yyyy) *
 
 Date Of Birth (mm/dd/yyyy) *
 
 
Emergency Contact Information
 Emergency Contact *
 
 Emergency Contact Relationship *
 
 Emergency Phone Number *
 
 Medications Taken During Dates Of Travel? *
 
 
Food & Beverage Information
 List Food Allergies- If None Write NONE *
 
 List Any Special Needs -such as Vegetarian, Vegan, special calorie requirements, etc.
 
 Like Spicy Foods?
 


 Food Dislikes-Please List
 
 Beverage Preferences-Please List
 
 
Island Excursions & Adventures
 Interested In Additional Activities?
 















 
If diving fill in the portion below:
 Certification Agency
 
 Certification No.
 
 Level Of Certification
 
 No Of Dives Logged
 
 Date Of Original Certification (mm/dd/yyyy)
 
 Date of Last Dive (mm/dd/yyyy)
 
 Will You Require A Refresher?
 


 Do you wish to dive Nitrox (32% Enriched Air) @ $12/tank?
 


 Do you have your own primary & back up lights for diving including batteries?
 


 How much lead weight do you expect to don in salt water (pounds)?
 
 Do you require rental gear?
 


 Rental Gear Required- Gear is Cressi Sub Brand, please indicate BCD & wetsuit sizes.
 













 Special Needs or Requests
 
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 Policy No.
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


Dive Fish Relax
 

For reservations and questions please contact:
Utopia Village at USA(817) 310-9343/ Honduras +504-3-344-9387
or complete our Reservations & Information Form

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