Booking form - Accessible Epic Enabled Safaris - disabled adventure travel, wheelchair holidays & family tours

		14 Clovelly Road Fish Hoek 7975 Cape Town SOUTH AFRICA Tel/Fax: +27 (0)21 782 9575 Mobile: +27 (0)73 22 82 82 5
	admin@epic-enabled.com
	Registration no: 1992/010887/23 - Vat no: 4750222350

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Specials

Booking Request

All fields indicated with a * are required. Your information will be treated as strictly confidential and only used for the purpose of your booking.

*Tour Name:

Tour Code:

Tour Date:

Travel Agent:

*Surname:

Sex:

*First Name:

Age:

Occupation:

Date of Birth:

year

Nationality:

Passport no:

Contact Address:

*E-mail:
Phone no:
Fax no:

Next of Kin address:

E-mail:
Phone no:
Fax no:

Insurance Details:
Company name:		Policy no:

House Doctor's name, address & contact no:

Description of Disability:

What is the cause of your disability?

Birth:

Illness:

Accident:

Other:

Do you use a wheelchair or walking aid?
Electric wheelchair:	Manual wheelchair:	Walking aid:	Crutches:	None:

Can you stand but require a wheelchair?

Yes:

No:

Can you transfer into a vehicle seat?

by myself:

with assistance:

I can’t transfer at all:

Are you on Medication?

No:

If yes, please describe:

Any other medical requirements we need to know about (i.e. heart problems, blood pressure etc):

Special Dietary Requirements:	Allergies:

What are your interests?
Wild life:	Bird watching:	Fauna & Flora:	Culture:	History:
Photography:	Other:

EPIC ENABLED TERMS - CONDITIONS & INDEMNITY

*I have read and fully understand and accept the booking terms and conditions set out overleaf, I voluntarily assume the risks of taking part in the excursions and I and my heirs, executors, administrators or assigns hereby indemnify, hold harmless and exempt EPIC ENABLED, its organisers, staff and agents from any liability due to damage, loss, accident, injury or illness suffered by or to myself howsoever arising and whether sustained directly or indirectly or in consequence of any act of negligence or omission or commission.

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