Emergency Info and Get to Know Before We Go! Traveler's Name * First Name Last Name Email * Emergency Contact Name First Name Last Name Emergency Contact Phone (###) ### #### Physician and Home Care aide (Personal Care Attendant) information: Please provide name, company/facility and phone/email Health Insurance Provider, Type of Policy, Group/ID # Native Language Would you be willing to authorize Empower Travel Companions to contact your physician and/or home care worker (PCA) for further information? Sure! No What is your code status? Do Not Resuscitate/Intubate or full support including CPR DNR/DNI Full Code Do you have a POLST or other health directive document(s)? Getting to Know You! What is the primary information you want your Companion to know about you? What is/was your occupation? Did you travel for work? What is your current living situation? What keeps you busy during the day? What do you do with your “downtime”? Do you have a pet? If so, do you need help in arranging care while you are away? When was the last time you traveled; where did you go? Describe your favorite trip and who you traveled with How do you currently feel about taking this trip? nervous, excited, etc Thank you!
