Special Assistance Form 2018-2019
Medical and Dietary Needs
Today's Date *
MM
/
DD
/
YYYY
Cruise *
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? *
I will be traveling with someone who will provide the assistance I require. *
Assistant's Name and Cabin Number
Your answer
Will you be using a wheelchair or scooter during the cruise? *
What type of mobility assistance will you be using?
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. *
I am requesting the following stateroom accommodations: *
Required
I require special table accommodations in the main dining room (please specify):
Your answer
Low vision: *
Required
Deaf / Hard of hearing: *
Required
Oxygen: *
Required
Dialysis: *
Required
Dietary restrictions: *
Required
Currently Assigned Dinner and Show Time: *
Other comments (can include allergies):
Your answer
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