Accessible Travel Request Form

Thank you for letting me help with your travel needs! As an Accessible Travel Planning Specialist, it is my goal to make your trip amazing and perfectly fit to your specific needs. I will leave no stone left unturned should you decide to proceed with using me and my travel services.

Full Name *

Phone *

Email *

City *

State *

Country *

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People"S Republic
Korea, Republic of
Kuwait
Kyrgyzstan
Land Islands
Lao People"S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Preferred Contact Method *

Phone

Text

Other

If Other, fill this field.

Travel Dates available (from) *

Travel Dates available (To) *

Are your dates flexible? *

Yes

Tell us more about your date flexibility... *

1) Provide details of your travel requirement

Paint us a picture of your ideal getaway! Are you envisioning a land-based adventure or a voyage at sea? Seeking rest and relaxation or craving non-stop nightlife? Share a glimpse of your travel needs to include preferred destination and the type of experience you're eager to have once you arrive!

Where do you want to go? Please tell us your preferred destinations: *

Customize your booking by selecting the travel elements you'd like to include? (Select all that apply) *

Flight

Hotel, Villa, Condo

Cruise

Airport Transfers

Flight & Hotel

Vacation Package

Train

Meals

Excursions

If Other, fill this field.

Please tell us your preferred departure airport / cruise port? *

What best describes your accommodation preferences? (Select all that apply) *

5-Star (Luxury)

4-Star (Moderate)

3-Star (lowest available pricing)

Vacation Home/Condo

Adults Only

All Inclusive

Kid /Family Friendly

Other

If Other, fill this field.

What kind of vibe are you looking for? *

Romantic

Fun / Daily Activities

Cultural

Luxury

Rest and Relaxation

Daily Activities

Adventure/Active

Other

If Other, fill this field.

What activities are you interested in? *

Beach And Water Activities

Adventure Activities

Tours/Culture

Nightlife

Gambling

Spa

Golf

Other

If Other, fill this field.

Want to elaborate on any other details your imagination is taking you? *

2) Booking Details

Travel Budget Details

What is your trip budget? It is ok to guess or state a range! We can discuss more later! *

If applicable, what size car rental will you need? *

Compact/Economy

SUV/Van/Pickup

Standard

Full Size

Accessible Van

Other

If Other, fill this field.

Tell us more about your travel companions!

Travel Companions: *

Infant/Toddler

Teens (13-19)

Seniors (55 + years young)

Veterans/Millitary

Childeren( <13)

Adults (20-59)

People who require some kind of accommodation for accessibility

First Responders

Anyone traveling for a special occasion? *

Birthday

Honeymoon

Destination Bachelor/ Bachelorette Party

Company Incentive/Reward Travel

Retreat

Anniversary

Destination Wedding

Family Getaway

Girl/Guy Trip

Other

If Other, fill this field.

Do any of the following apply to you or anyone you are traveling with? *

Slow/limited walking with our without cane/walker

Uses some type of wheeled mobility (wheelchair, scooter, powerchair etc)

Needs physical assistance to transfer

Requires specific bed height for transfers and safety

Sensory Sensitive/Neuro Diverse

Special Dietary Consideration

Unable to go up/down stairs with/without assistance

Needs a wheelchair accessible van

requires a use of lift for transfers

Roll in or Walk in Shower Required (No Tubs)

Requires Grab Bars near toilets

Requires Hospital Bed or special sleeping arrangements

Requires the use of supplemental oxygen

Needs a shower or tub bench to safely shower

Is on Hemo Dialysis

Has Diabetes or other medical complexity

Hard of Hearing

Low Vision

Mental Health/TBI/Invisible Disability

Cognitive Impairment/Dementia

Has issues with dizziness or vertigo

Service animal traveling with you

3) Final Thoughts?

Is there anything else we should be aware of? Feel free to share any additional details about your party, budget, or travel preferences that will help us create a customized and exceptional experience for you.

Accessible Travel Planners, LLC

Accessible Travel Planners, LLC