This form serves as a contract between you, the client/key worker/parent and Go Provence Supported Holidays Ltd.
Please complete this form truthfully and with as much information as possible.
We will create an individual care plan for each client based on the information that you have given us. If the information you provide is incorrect or lacking in detail, not only may it result in a situation that is distressing to the client and other clients on the same holiday, but also it may incur additional costs at your expense to cover any additional support. Please read our terms and conditions.
1. Name
2. Address
3. Telephone number
4. Holiday dates required:
5. Have you travelled with Go Provence before?
6. Are there any dietary requirements? For example, vegetarian, allergies, religious reasons, medical reason.
7. Do you have any assistance with eating. For example, do you have adapted cutlery? Does your food need to be of a soft texture for denture reasons?
8. Do you smoke?
9. Do you drink alcohol rarely, sometimes and regularly?
10. Do you require Personal Care? Please tick next to the type of care you require and provide details of exact support needed.
a. Help with brushing teeth
b. Shaving
c. Washing
d. Brushing hair
e. Dressing
f. Periods, support with period pains and pads.
g. Support with visiting the toilet.
h. Support getting in and out of shower
11. What are your mobility needs? For example, do you need help climbing stairs? Can you walk long distances? Do you need help getting in and out a mini bus?
12. Do you require any communication needs? For example, Makaton, BSL.
13. Are you visually impaired?
14. Do you wish to share a room? You will be charged accordingly for this.
15. Do you have any phobias? For example water, heights, crowds, insects, the dark.
16. Are you epileptic? If yes please provide exact details.
17. Do you have any allergies which could result in an anaphylactic shock? If yes please outline what may trigger your reaction. Do you carry a syringe or auto-injector of epinephrine?
18. Do you have a heart condition? If yes please give details.
19. Do you faint from time to time or experience dizzy spells? If yes please give details.
20Do you experience with regular headaches or migraines? If yes please give details. What medication do you take for this?
21Do you experience nausea, for example during travelling?
22Do you experience home sickness?
23Do you experience insomnia or any problems with sleeping, for example bed wetting?
24. Are you affected by any other medical ailment that we have not asked, that you feel we should be aware of to ensure your safety during your stay with us?
25. Please give details of any medication that you take and may need support with each day.
26. Do you require support when handling money?
27. Do you have a phobia of flying?
28. Name and contact details of next of kin:
29. Two other Emergency contact numbers and relationship to client:
Important ID information required by airlines to enable travel 1. Date of Birth
2. Place of Birth
3. Nationality:
4. Passport Number:
5. Date of Issue of passport
6. Date of expiry:
Please confirm that you have read our Terms and Conditions by writing Yes in space provided_____________________.
I (name of client or clients advocate) .declare that the above information is true.