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| Name: |
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| Address: |
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| City: |
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| Zipcode: |
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| Country: |
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| Phone day: |
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| Phone evening: |
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| E-mail: |
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| Fax: |
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Choice of country: |
Spain
South Africa |
| Choice of hotel or apartment in Spain:
|
| Supplements?
Breakfast
Half board
Full board |
| The length of your stay:
|
| The date of your stay from - till: |
| Choice from
Till
|
| Choice in South Africa: |
|
Self drive holiday
Group travel:
7 Days
12 Days |
| Do you need rental equipment:
|
| Transfer in:
Self propelled wheelchair
or
Motorized wheelchair |
| Will you require a shower/WC chair?
Yes
No |
| Number, name and age of persons travelling with you: |
| 1. Name
Age
|
| 2. Name
Age
|
| 3. Name
Age
|
| 4. Name
Age
|
| City of departure:
|
CONFIDENTIAL HEALTH &
EMERGENCY INFORMATION
|
Please answer all questions thoroughly!
|
| Date of birth |
|
| Sex |
Male
Female
|
| Your weight |
|
| Your height |
|
| My upper body strength is:
poor
not bad
good |
| Are you currently under the care of any medical specialists? |
|
No
Yes If yes, for what conditions: |
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| Your health insurance company and policy number: |
|
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| The name of your physician & telephone number: |
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In case of emergency who should we call?
Name and phone
number: |
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|
 |
Within 10 days you will receive your confirmation,
your invoice and payment instruction. |
DON'T FORGET YOUR TRAVEL
INSURANCE |
| RELEASE OF LIABILITY: |
Please
read carefully and mark the checkbox below if you
agree to all of the terms. |
I certify that the above information is true, accurate and complete.
I certify that I and/or my companion(s) (including minor children) are fully
capable of participation in the trip and booked activities. I hereby waive,
release and discharge all actions, claims and demands for personal injury
and/or property damage that may hereafter accrue against Wheels on Holiday, its
employees, agents, hotels and/or resorts, arising out of ordinary negligence.
This agreement shall be governed by and constructed in accordance with the law
of Spain.
I understand that in case of cancellation of my trip the deposit
is non-refundable.
I have read, understand, and accept the terms and conditions stated
in here and acknowledge that this agreement shall be effective
and binding upon me and my companions during the entire period of my vacation. |
| Yes, I agree |
PLEASE MARK THE CHECKBOX ABOVE
AND E-MAIL IT TO
WHEELS ON HOLIDAY.
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