Are you the Traveler?
(If you are not the traveler - please fill out contact person information below)
Traveler Name
*
First Name
Last Name
Traveler Email
*
Contact Person Information
If you are not the traveler - please give your name, email, phone and address.
Traveler Date of Birth
MM
DD
YYYY
Traveler Phone
(###)
###
####
Traveler Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Preferred Method of Contact
Height
Weight
What medical or mental health concerns or conditions are you currently experiencing?
What medications do you currently take? Please give the prescription name and what it is for, or provide a medication list.
Briefly describe your past medical history.
Do you use any medical devices (i.e., hearing aid, glasses, walker, cane, CPAP, oxygen, EZ or hoyer lift, manual or power wheelchair)
What restrictions do your medical conditions, medications or devices have on your activities of daily living?
How would those restrictions impact your mobility/ability to travel?
I can
If flying, what do you have for identification and when does it expire? (We can discuss alternatives to a valid state ID card or driver’s license, if relevant).
Please list any TSA known traveler or Clear numbers, or relevant frequent flier numbers
Do you anticipate any problems with or have concerns regarding transportation (i.e. car sickness, fear of flying, incontinence)?
What type of lodging do you desire?
How near would you like your Companion to be on overnight stays?
Describe the level of attention you would prefer to receive from your Companion:
How often do you like to eat and what kind of restaurants or food do you prefer? Do you have any food allergies or require any special diet?
What time do you like to get up in the morning and retire at night? What rest, if any, do you need during the day?
Do you need, or would you like help with, activities of daily living (i.e. dressing, bathing, grooming) and if so, what do you anticipate?
To what extent, if any, do you want to handle cash and/or financial transactions?
What insecurities, if any, do you have about traveling (i.e. what might create stress for you)?
Describe what would make this trip special and memorable for you.
