Accessible Travel Needs Assessment Form
Personal Information
Full Name
Email Address
Phone Number
Travel Details
Destination
Departure Date
Return Date
Accessibility Requirements
Mobility Needs
Wheelchair access
Walker/cane support
Limited mobility/assistance
None
Visual Assistance
Blind/low vision support
Large print materials
Guide dog access
None
Hearing Assistance
Sign language interpreter
Assistive listening device
Captioning services
None
Other Accessibility Needs
Medical Information
Relevant Medical Conditions
Additional Comments
Comments or Special Requests