Vacationers
Name as it appears on Govt issued ID:
Vacation Choice:
Date
of Departure:
City of Departure:
Can
Vacationer travel alone by air?
Yes
No
SSN:
Eye Color :
Hair Color:
Weight:
Bithdate (MM/DD/YYYY):
Sex:
Male
Female
T-Shirt Size: SmallMedium LargeX-Large
Address:
Street:
Apt #:
City:
State:
Zip:
24 hour emergency contact:
Phone Number:
Agency
Name:
Staff Person:
Physicians Name:
Phone Number:
Insurance Company:
Policy Number:
VERY
IMPORTANT MEDICAL RELEASE INFORMATION
This section must be read and completed by participant
or legal guardian
In
case of an emergency, accident or illness; I give
my permission to be treated by a professional medical
person and to be admitted to a hospital if necessary.
I agree to be responsible for all medical expenses
incurred on my behalf.
I
agree
I disagree
Name:
Today's Date:
Signature:_______________________________
MEDICAL
INFORMATION - IMPORTANT
Does
Vacationer have any of the following medical conditions
(check all that apply):
Diabetes
Heart Condition
Respiratory Condition
Seizures:
Yes
No
Type:
Frequency:
Last seizure date:
List any instructions:
Allergies:
Dietary
Restrictions (Please List):
MEDICATIONS:
Vacationer
handles meds
Tour escort dispenses them
Please Fax any additional medication
information to (503) 738-3369
TELL
US ABOUT YOURSELF!
Do
You...
Swim?
Yes
No
Smoke?
Yes
No
Consume Alcohol?
Yes
No
Use Sign Language?
Yes
No
Wear a hearing aid?
Yes
No
Wear Glasses?
Yes
No
Wear Dentures?
Yes
No
Tire easily?
Yes
No
Can
You...
Communicate Verbally?
Yes
No
Handle your own money?
Yes
No
Are
You...
Able
to walk long distances?
Yes
No
In a wheelchair?
Yes
No
Would
You...
Like the escort to handle
your meds?
Yes
No
Like the escort to handle your money?
Yes
No
This
section is for you to tell us about yourself. Let
us know what we can do to make your tour more enjoyable.
List any behaviors or problems that might occur while
your with us. Let us know if you have any hopes or
wishes, we'll see what we can do!