Special Needs Request Form

Please complete the following form and we'll pass on the information to the tour operator or airline as soon as possible.


Print this 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 your request being denied by your tour 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 and 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 with you ?
(Please make a note of all equipment in Section D: Extra Notes)		   
Yes   No
Are you asthmatic or do you have other breathing difficulties ?   
Yes   No


Section D. Extra Notes
Any other 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.
Alternatively, you can post the completed form to:

Customer Services
Flightline Essex Ltd.
32-38 Milton Road
Westcliff-on-Sea
Essex
SS0 7JE


June 19, 2013, 3:20 am
http://www.flightline.co.uk/help/special-needs.php