Special Needs Request Form

Passenger Details

Lead Passenger Name:
Passenger Requiring Assistance:
Departure Date:	(dd/mm/yy)
Document No. / Booking ID:
Outbound Flight No:
Outbound Flight Details:
Contact Email Address:

Section A. General Details

What is the medical term for your disability or special need?

Disability Badge Number:
(Failure to provide this, may result in request being denied by your operator)

Please Note: A doctors "fit-to-fly" certificate may be required

Section B. Mobility Details

Do you have any mobility difficulty? (If No then continue to Section C: Flight Details)	Yes No
Can you walk on your own without assistance?	Yes No
Can you walk up and down aircraft steps?	Yes No
Do you need to borrow a wheelchair to & from the aircraft?	Yes No
Can you board or leave an aircraft or coach without additional assistance other than from a travelling companion?	Yes No
Are you taking your own wheelchair? (If No then continue to Section C. Flight Details)	Yes No
If you are taking a wheelechair, is it collapsible?	Yes No
If you are taking a wheelechair, is it battery operated?	Yes No
If you are taking a wheelechair, which battery (cell) does it use?	Wet Dry
If you are taking a wheelechair, what are its dimensions? (Please state Width / Height / Depth & state in CM or INCHES)	Open: Closed:
If you are taking a wheelechair, what is its weight? (Please state weight in Kg or Ibs)	Weight:

Section C. Flight Details

Would it be best for you to sit near a toilet?	Yes No
Would it be best for you to have an aisle seat?	Yes No
Will you be taking medication during the flight?	Yes No
Will you be taking any medical equipment? (Please make a note of all equipment in Section D)	Yes No
Are you asthmatic or you have other breathing difficulties?	Yes No

Section D. Extra Notes

Any information we should be aware of or medical equipment details?

Important Information - Please Read

The above information will be passed to your Tour Operator or Airline. They will endeavour to meet your special assistance needs. However it is very important to remember that your special assistance needs requirements cannot be guaranteed. Also in some cases a medical certificate may be required before the requests can be met.

A special assistance needs form has to be returned to us by not later than 2-weeks prior to departure. If less than 2-weeks prior to departure, the special assistance needs form should be sent to the airline directly.

Please make sure that your holiday insurance adequately covers any pre-existing medical conditions and any expensive equipment that you may be taking with you.

By completing this form you declare that:
A) You are over the age of 18

B) All of the information on this form is true and correct and you understand that there can be no guarantee that these special assistance needs will be met.