SPECIAL NEEDS

INFORMATION CHECKLIST

We want all our customers to enjoy completely successful travel arrangements. This checklist must be completed before confirming a booking for any customer who has a medical condition or disability requiring special travel, accommodation or dietary arrangements. Ask the customer the following questions and write the answers on this checklist. This information must be used to check the suitability of the accommodation and the resort.

Lead Name

x

Customer Name

Departure Date

Booking Ref:

A.GENERAL

1.What is the medical term for your disability/special need?

B.MOBILITYTick as appropriate

YESNO

1.Do you have any mobility difficulty?

(If no - move to Section C - FLIGHT/COACH TOUR)

2.Can you walk on your own without assistance?

3.Can you walk up/down the aircraft steps?

4.Are you taking your own wheelchair?

4a.Is it collapsible?

4b.(Dry cell only) Is it battery operated?

4c.(Wet cell only) Is it battery operated?

5.Do you need to borrow a wheelchair to/from the aircraft?

6.Can you board and leave a standard coach without additional

assistance other than from your travelling companion?

7.Do you need a taxi transfer from the airport to

your accommodation and return?

8.What are the dimensions and weight of your wheelchair?

OPEN:Width . . . . . . . . . . . . . . insHeight . . . . . . . . . . . . . . insDepth . . . . . . . . . . . . . . ins

CLOSED:Width . . . . . . . . . . . . . . insHeight . . . . . . . . . . . . . . insDepth . . . . . . . . . . . . . . ins

WEIGHT:

C.FLIGHT/COACH TOURTick as appropriate

YESNO

1.Is it best for you to sit adjacent to the toilet?

2.Is it best for you to have an aisle seat?

3.Do you prefer a no smoking seat?

4.Will you be taking medication during the flight?

5.Are you taking any medical equipment?

6.Are you asthmatic or do you have other breathing difficulties?

7.Are you likely to require oxygen?

D.ACCOMMODATION

1.Can you walk up/down steps?

2.Do you prefer a low floor room?

3.Do you prefer a room near the lift?

4.Would you like medication to be stored in a fridge?

E.MEALS

1.What is your special dietary requirement?

IMPORTANT CUSTOMER INFORMATION

The above information will be passed on to your travel supplier, who will do their best to meet your special needs. However it is very important to remember that special needs cannot be guaranteed. Please check that your holiday insurance policy adequately covers any pre-existing medical condition and covers any expensive equipment you may be taking.

I have read and agree to all the information on this form and understand that there can be no guarantee that these special needs can be met. I further understand that this information may be placed on a computer system by my travel supplier, but that it will not be communicated to any party which is not responsible for the supply of my travel arrangements.

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CUSTOMER SIGNATURE / DATE

(I am over 18 years of age)