Name
Date of Birth
Phone No:
Email:
Address
Next of Kin (name, address & phone no)
What is your disability? Please give specific details in full.
Please give details of what aids you use: (wheelchair, scooter, walking stick etc;)
If you use a wheelchair please give dimensions if not standard.	Length:   Width:     Weight:
Do you require any special help not already stated above?
Holiday option chosen eg: Cape Town only, Cape Town & Garden route etc;)
Carers can be arranged from the UK only. Do you require this service?	YesNo
Signed
Date