Trip Signup | Tulip Travel

- Step 1 of 2

Traveler Information

Name *

First

Last

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Agent Information

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Trip Information

I want to sign up for multiple trips *

First Choice of Trip Date *

Second Choice of Trip Date *

Third Choice of Trip Date

Fourth Choice of Trip Date

Where to Send Information to: (Traveler, agency, etc.)

Any Special Equipment needed (eg. Wheelchair, walker, etc.)

Would you like to purchase travel insurance?

Yes
No
Not sure- I need more info

Traveler Identification

Upload your Government ID:

Drag & Drop Files, Choose Files to Upload

Upload your passport (if you have one):

Drag & Drop Files, Choose Files to Upload

Customer Profile

Please take a moment to fill out completely. Your trip request is incomplete without this profile information.

Traveler Name *

First

Last

Date of Birth

MM/DD/YYYY

Name of Traveler as it appears on government issued photo ID:

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Traveler Phone

Vacation Destination & Date *

Emergency Contact *

Emergency Contact Phone *

Agency Info

Please fill this out ONLY if you are represented by an agency.

If affiliated with an agency, what is the agency:

Agency address:

Agency Phone

Alternate Phone (Mobile)

Fax

Agency contact person

Title

Medical Information

Please fill out as accurately and completely as possible.

Applicants diagnosis

Insurance Provider

Policy Number

Nurse On Call

Emergency Contact (Medical)

Medication Management

Medication Administration

Independent
Supervision
Assistance

Current Medications

A Medication Administration Record may be supplemented

Medication

Medication Dose

Medication Time(s)

Medication

Medication Dose

Medication Time(s)

Medication

Medication Dose

Medication Time(s)

Medication

Medication Dose

Medication Time(s)

Medication

Medication Dose

Medication Time(s)

Medication

Medication Dose

Medication Time(s)

Medication

Medication Dose

Medication Time(s)

Medication

Medication Dose

Medication Time(s)

Medication

Medication Dose

Medication Time(s)

Medication

Medication Dose

Medication Time(s)

Over the counter medications

Does the traveler take any over the counter medications

Name OTC

OTC Dose

PRN

Name OTC

OTC Dose

PRN

Name OTC

OTC Dose

PRN

Name OTC

OTC Dose

PRN

Food/Allergies

Does the traveler have any known food allergies we should know about?

Allergies

Please list any dietary restrictions (non-allergy)

Safety Concerns

Does the traveler have any medical conditions that prevents him/her from going on amusement park rides and/or roller coasters?

Does the traveler need a wheelchair?

Does the traveler need a walker?

Does the traveler smoke?

Can traveler have alcoholic beverages?

Please describe any other medical issues that Tulip Travel should know about

Social/Behavioral

Please give a short description of yourself (your likes and dislikes, favorite food, etc.)

Does the traveler follow a behavior plan?

Is traveler allowed to swim?

How would you rate traveler’s swimming skills:

Excellent
Fair
Poor

Does traveler have a history of seizures?

Will traveler be bringing a Personal Floating Device?

Notice:

All travelers with a history of seizures and/or poor swimming skills will need to bring a PFD (life jacket) on
their trip in order to participate in any swimming/water activity. Tulip Travel does not provide life jackets for travelers on their trip. Swimming will only be allowed at hotels and resorts with a certified life guard on duty.

Does the traveler like amusement park rides?

Does the travel have any fears (heights, darkness, lightning)?

If yes, please explain

Self-Care Skills

Dressing

Independent
Needs Assistance

Please explain if needs assistance w/ dressing

Bathing

Independent
Needs Assistance

Please explain if needs assistance w/ bathing

Toileting

Independent
Needs Assistance

Please explain if needs assistance w/ toileting

Eating

Independent
Needs Assistance

Please explain if needs assistance w/ eating

Hygiene

Independent
Needs Assistance

Please explain if needs assistance w/ hygiene

Please describe any other assistance for self-care needs

Money Management

Traveler handles own money?

Needs supervision when purchasing?

Escorts should keep control of my money?

Our Travel Escorts are prepared to lead a safe and enjoyable vacation. Customers applying for the trip do so at their own risk, and release Tulip Travel, Inc. and its staff from liability for any harm to person or property that may occur. Customers are advised to carry their own medical insurance and/or traveler’s insurance. If a customer has to be removed from the tour for medical, behavioral, or psychological reasons, the customer must pay the cost of return. Tulip Travel, Inc. is granted permission to use trip photographs of a customer for promotional purposes. Completion of this application implies understanding and agreement to these conditions.

Authorized Name *

First

Last

Date / Time *

Date

Time