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Medical Details *
Any dietary requirements? *
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if Yes please specify

Any medication? *
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if Yes please specify

Any current / past illnesses or disabilities? *
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if Yes please specify

Checked the PADI medical statement? *
No Yes

Link to PADI medical statement
Dive experience
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Number of dives done
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When would you like to go?
If you have specific dates / range of dates, please specify
For how long?

Which country / courses are you applying for? (if more than one course per country use both boxes below)
Australia
 
Belize
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Where did you hear about PoD?
Internet search engine main listings e.g. Google
Google sponsored link (box on side of Google page)
gapyear.com
responsibletravel.com
Newspaper / magazine advert
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Personal recommendation
(please specify who)
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