China Accessible Travel

Holiday details:

The tour code you choose is：

Number of Travellers：

Passengers:

Mr. Mrs. Miss
First Name：	Surname：
Nationality：	Date of birth：
Address：	City：
State： Zip： Home phone：
E-mail:	Fax：
Please describe your physically disabled condition simply：

Name of able bodied traveling companions：
1、 2、 3、
if travelling with a companion can she/he look after you yes no
and provide all the assistance you need?： yes no
Do you require insurance? yes no
Airport/city you will depart from：
Do you prefer： smoking no smoking	Are you confined to a wheelchair： yes no
	If NO please state how far you can walk
Can you climb 5 steps unaided?
Are you taking your own wheelchair?
Does it collapse for transportation?
Are you taking a powered wheelchair? yes no
If "YES" please provide details：
Height cm Width cm Depth cm Weight kg
Please confirm battery type：
Do you require a special diet on the flight? yes no
If "YES" Please select： none vegetarian vegan other
if diet not listed give details in special notes box
On board the flight do you require seats close to the toilets？ yes no
Do you give us permission to contact your Doctor in case of difficulties or problems? yes no
Name and address of your doctor：
Where in China would you like to go？
Other special needs：