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FILL OUT THE FOLLOWING FORM TO HELP US PLAN THE PERFECT GALAPAGOS DIVING ADVENTURE FOR YOU.

APPLICATION FORM















XS: S: M: L: XL: XXL:

XS: S: M: L: XL: XXL:


Indicate with an X if you have experience in the following diving conditions:
7mm Wetsuit : Currents : Wall : Reef :


In case of emergency contact (name, address, phone):



Answer YES or NO to the following medical conditions:
Asthma: Yes  No
Diabetes: Yes  No
High blood pressure: Yes  No
Heart Disease: Yes  No
Convulsions, Epilepsy: Yes  No
Chronic Nasal Congestion, Sinusitis, Otitis, Bronquitis: Yes  No


IF YOU HAVE ANY MEDICAL CONDITION AND/OR IF YOU ARE MORE THAN 55 YEARS OF AGE AND HAVE NOT BEEN DIVING FOR MORE THAN 6 MONTHS, YOU WILL NEED TO PRESENT A MEDICAL CERTIFICATE UPON YOUR ARRIVAL AT THE DIVE CENTER.


Address: Avenue Charles Darwin - Puerto Ayora, Santa Cruz - Galapagos, Ecuador
Phones: Office: (593-5) 2-526497    Cell: (593) 97024031
E-mail:info@scubaiguana.com