5 Day Garden Route Booking

Personal Details

Name*

First Last

Date of Birth*

dd/mm/yyyy Age

Nationality*

Passport Number

Contact Details

Your Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Telephone number*

With country code, example: +27 21 7857440

In case of emergency

Next of Kin name*

First Last

Next of Kin address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Next of Kin telephone number*

With country code, example: +27 21 7857440

Next of Kin email

Your health & disability

Insurance company name*

Insurance policy number*

House Doctor's name, address & contact number*

What is the cause of your disability?*

Description of disability

Do you use any of the following?*

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

If you are on medication, please describe

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

Special Dietary Requirements

Allergies

How did you find out about Epic Enabled?

Promotional code (optional)

Subject to Epic Enabled's approval.

Tour date & pricing

Tour Date

Terms & Conditions

Please click here to read Terms & Conditions

Please tick*

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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Personal Details

Contact Details

In case of emergency

Your health & disability

Tour date & pricing

Terms & Conditions

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