If any of the above are aged under 16 years please give name and date of birth
If more than 1 child please give details in SPECIAL NOTES box

Do you require insurance? YES NO
If NO please give details of your policy in SPECIAL NOTES box

Are any of the above aged 70 years or over YES NO

Please note that persons undergoing treatment, on any medication or over 70 MUST obtain confirmation from their G.P. that there is NO objection to travel.
Some airlines require a doctors note.

Name of Disabled Traveller

IF MORE THAN 1 DISABLED PERSON PLEASE FILL IN ADDITIONAL BOOKING FORM

Date of Birth

Condition or Disability of above named

Anyone with a severe chronic condition will be referred to the Insurers for a review of their cover.

Are you confined to a wheelchair? YES NO

If NO please state how far you can walk

Can you climb 5 steps unaided? YES NO N/A

Are you taking your own wheelchair? YES NO

Does it collapse for transportation? YES NO N/A

Are you taking a powered wheelchair? YES NO
If "YES" please provide details

ELECTRIC WHEELCHAIRS

Please confirm battery type type N/A GEL SEALED ACID

Do you require a special diet on the flight? YES NO

If "YES" Please select:- VEGETARIAN VEGAN COELIAC OTHER NONE
if diet not listed give details in special notes box

As none of the resorts or properties have been fully planned for independent living
if travelling alone will you be able to cope with every aspect of the holiday? YES NO N/A

or if travelling with a companion can she/he look after you
and provide all the assistance you need? YES NO N/A

On board the flight do you require seats close to the toilets YES NO N/A

Name and address of your doctor


Do you give us permission to contact your Doctor in case of difficulties or problems YES NO

CAR RENTALS (if applicable)

Driver's Name

Number of years driving Age

Hand-control cars are available in Florida, and the Algarve on request

SELF DRIVE- Car details (if applicable)