Booking Form
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Please print this form, complete and return to us, so that we may assess your
needs.
Holiday Dates: ................................................................................... Name: .................................................................................. Address .................................................................................. Town .......................................................... County.............................................................. Post Code ........................................... Telephone Number ............................................ Age ......................... Date of Birth ................................ Sex M/F .......... Religion ......................................... Disability Diagnosis (if any) ..................................................................... Learning Disabilities: Severe Moderate Mild (Please circle) Do your require transport? ...................................... Do you require a single room (at extra cost, subject to availability) ......................... Name and Address to whom invoices and details should be
sent : ................................................................................................................. ................................................................................................................ Tel. No. ................................................. Emergency ................................ Doctors Name ................................................................................ Address ................................................................................................................. ................................................................................................................ Tel No. ................................................. NHS No ..........................................
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MOBILITY please tick relevant section.
CLOTHES
CONTINENCE
Uncontrolled incontinence can cause serious problems (for us and other guests) on long car journeys so, should this problem be far more serious than disclosed at the outset, it would make it impossible for the guest to travel in the vehicle. SPEECH
BEHAVIOUR
Are you on a special diet? (Please state) What do you prefer to drink? Tea .... Coffee .... Cold ....Drinks.... Other................... Are you allowed to drink alcohol? ................................................... Do you require any assistance with eating? .................................................. ABOUT YOU
Do you smoke? ....................................If so,
how any a day? ......................... MONEY Are you able to handle your pocket money:
MEDICAL HISTORY Please detail any medical conditions (including allergies. Epilepsy, stating whether self medicating or not) together with a list of medication and dosage, plus any information you feel we should know. ...................................................................................................................................................... ..................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ..................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... |