In order to ensure a completely enjoyable expreience, we need to know a little about you and your travel needs. Please provide all requested information. All information is kept strictly confidential. Your quote will be sent to you as soon as possible.

PERSONS TRAVELING:
Please list name as show on your drivers license, state ID or passport:

Traveling Person 1:    Age:
Traveling Person 2:    Age:
Traveling Person 3:    Age:
Traveling Person 4:    Age:
Traveling Person 5:    Age:
Traveling Person 6:    Age:


AIRLINE INFORMATION:

Departure City:                Arrival City:            
Approximate Departure Date/Time:            

Departure City Return:    Arrival City Return:
Approximate Departure Date/Time Return:


GROUND TRANSPORTATION:

Do you need ground transportation: 
Car, Limo, Van:                                   
Transfer to what location:                   


MOTEL/HOTEL/RESORT:

Do you need a hotel, motel, or resort:
Location:   Price Range:                     
Date In:                      Date Out:                           
Number of beds:      Smoking or Nonsmoking:
Special Requests:


ACCESSIBILITY INFORMATION:

What is your disabilty: 
What type of aids do you require to take on your trip:
If you use a wheelchair, are you able to stand without assistance, walk without assistance or transfer seats without assistance:      
Wheelchair specifics - Manual or Electric: 
If electric, what type of batteries (non-spilliable, dry cell, gel cell, acid packed): 
Will you transfer to a regular seat in a wheelchair van, or remain in your wheelchair: 
Your weight: (I won't tell) 
Will you be taking any required equipment such as respirator or oxygen: 
If yes, please explain:     
Seat preference (window or aisle): 
Special Meal Request :   
Will you be traveling with a companion who will assist you: 

Other Requests:


YOUR INFORMATION:

Your Name:         
Mailing Address:

Day Phone:      Night Phone:      Fax Phone:  

EMail:

Additional Comments:

Please contact me by: E-Mail Day Telephone Night Telephone Fax Mail

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