Special Assistance Form 2018-2019
Medical and Dietary Needs
* Required
Today's Date
*
MM
/
DD
/
YYYY
Cruise
*
Malt Shop Memories Cruise 2018
Southern Rock Cruise 2019
Soul Train Cruise 2019
The Country Music Cruise 2019
Ultimate Disco Cruise 2019
'70s Rock and Romance Cruise 2019
Flower Power Cruise 2019
First Name
*
Your answer
Last Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Cabin Number
*
Your answer
Is your cabin handicap accessible?
*
Yes
No
I will be traveling with someone who will provide the assistance I require.
*
Yes (please provide information below)
No
Assistant's Name and Cabin Number
Your answer
Will you be using a wheelchair or scooter during the cruise?
*
Yes - Bringing my own
Yes - Delivered by outside vendor
No
What type of mobility assistance will you be using?
Scooter
Manual wheelchair
Motorized wheelchair
Cane/Walker
Other:
What is the width (in inches) of the wheelchair or scooter?
Your answer
I am requesting that a wheelchair be provided for embarkation and disembarkation only.
*
Yes
No
I am requesting the following stateroom accommodations:
*
Raised toilet seat
Shower stool
Commode chair
Refrigerator for medication
Hypodermic disposal facility (sharps container)
Distilled water for CPAP/BIPAP
Extension cord
None
Other:
Required
I require special table accommodations in the main dining room (please specify):
Your answer
Low vision:
*
Blind
Legally blind
Bringing a service dog (please contact our office for additional forms)
None
Other:
Required
Deaf / Hard of hearing:
*
Deaf
Hard of hearing
Request visual-tactile alert system in stateroom for door knocking, smoke detector, and telephone ringing
Assistive listening device in the main theater
None
Other:
Required
Oxygen:
*
Bringing oxygen on board
Oxygen delivered by outside vendor (please include vendor name and phone number in the "Other" box)
None
Other:
Required
Dialysis:
*
Hemo-dialysis (assistance unavailable-please make sure you can manage this on your own)
Peritoneal dialysis (if supplies provided by outside vendor, please include vendor name and phone number in the "Other" box)
None
Other:
Required
Dietary restrictions:
*
Diabetic
Vegetarian
Vegan
Kosher (must be ordered at least 90 days prior to sailing)
Halal
Gluten-free
None
Other:
Required
Currently Assigned Dinner and Show Time:
*
Early Dining / Late Show
Late Dining / Early Show
Early Show (Southern Rock ONLY)
Late Show (Southern Rock ONLY)
Other comments (can include allergies):
Your answer
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