Registration Raja Ampat 12 2023

Raja Ampat Escape Registration

First Name

Last Name

Street Address

City

Region/State/Province

Postal / Zip code

Phone

Your Birthdate (Day, Month, Year)

Passport Number (If International Escape)

Expiration Date

PADI # (Enter Student if Not Certified Yet)

PADI Certification Level (Student, OW, AOW, Rescue, Etc)

My Travel Companion's Name Is:

Companion's Email

Companion's Phone

Companion Date of Birth (Day, Month, Year)

Companion Passport Number

Companion's Expiration Date

Companion's PADI #

Companion Certification Level

Please note any allergies here as well as any other special concerns we need to be aware of for you.

Travel Companion: Please note any allergies here as well as any other special concerns we need to be aware of for you.

I understand this is a nonrefundable deposit to hold my spot on the Raja Ampat December. This will block others from taking this spot. Final price of the trip will be available within 30 days of deposit. I agree that any photos or videos or likenesses taken of me or my children while on this trip or while at any SSE event are the property of Southeast Scuba Escape and I authorize SSE to use them without further authorization or compensation to me or my family for promotional and marketing purposes. I understand I must meet medical standards an PADI medical questionaire may require a physican clearance to dive. I also understand that I may be required to have proof of COVID-19 Vaccination and that I should ensure my passport has at least 6 months before expiration from the date of my return from international destinations, and that I should purchase travel insurance to protect my investment in this vacation. I understand that Southeast Scuba Escape (SSE)is not able to refund the cost for this or other escapes should I not be able to attend after registering and paying for the trip. SSE will host a bon voyage meeting prior to departure in person or via Zoom to review final details and get participants together to meet, review gear needs, and go over all travel and escape details and requirements.

Your Signature

Companion Signature (Enter None if No Companion)

If registering a travel companion please remember to select the appropriate number of deposits to pay. If registering more than one travel companion please complete a separate registration.

I will register additional travel companions: