ADDRESS

CITYSTATE/PROVINCE

POSTAL ZONE(ZIP CODE)

COUNTRY

E-MAIL ADDRESS

MONTH

DAY

YEAR

SEX MALE FEMALE

>WOULD YOU LIKE A MALE OR A FEMALE ATTENDENT? NO PREFERENCE

DISABILITY OR ILLNESS (PLEASE TELL US WHAT YOUR DISABILITY OR ILLNESS IS IN THE SIMPLEST TERMS- THANK YOU):

MEDICATIONS: (PLEASE DECRIBE ALL MEDICATIONS TAKEN, BE THEY "OVER THE COUNTER" OR PERSCRIPTION, ALSO PLEASE GIVE TIME OF DAY TAKEN AND MILIGRAMS OF MEDICATIONS- THANK YOU.)

MEDICAL SUPPLIES: (SUCH AS- WHEEL CHAIRS,WALKER, CANE, TED HOSE, CATHETER ...)

YOUR MEDICAL,PERSONAL, AND AUTO INSURANCE OR CO-INSURANCE (PLEASE JUST THE COMPANIES NAMES NOT YOUR POLICY NUMBERS AT THIS TIME [IE,- MED-CAL,MED-CO,MED-CARE,FARMERS,STATE FARM,AND SO ON...]-THANK YOU):

DESTINATION:

DATE OF YOUR DEPARTURE?

MONTH

DAY

YEAR

DATE OF RETURN?

M ONTH

DAY

YEAR

HOW LONG WILL YOU BE STAYING AT YOUR DESTINATION?(IN DAYS):

TRAVEL TIME (TIME YOU WILL SPEND ON YOUR TRIP):

ORIGIN (STARTING PLACE):

FINAL DESTINATION (ENDING POINT[IF SAME AS ORIGIN LEAVE BLANK]):

WHAT MODE OF TRANSPORTATION WOULD YOU LIKE TO TRAVEL BY (CAR,VAN WITH A LIFT OR RAMP,TRAIN, AIRPLANE?):

IF YOU ARE USEING A CAR/VAN WOULD YOU LIKE TO USE YOUR OWN CAR/VAN? A RENTAL CAR/VAN?

ARE THERE ANY OUTHER THINGS THAT TRAVEL AIDES INTERNATIONAL MAY NEED TO KNOW ABOUT YOUR TRIP? (SUCH AS: SPECIAL TREATMENTS THAT WE MAY NEED TO TAKE YOU TO AT YOUR DESTINATION? LODGING ACCOMMODATIONS? TRANSPORTATION TO AND FROM EVENTS AT DESTINATION? AND SO ON...):

DO YOU WANT TO TAKE A PET?-PLEASE TELL US ABOUT YOUR PET (WHAT TYPE? CARE? SPECIAL NEEDS FOR YOUR PET? SEEING EYE? COMPANION? SERVICE DOG? AND SO ON...)):

YOUR LANGUAGE?

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