Name:___________________________________ D.O.B.:_______________________

Address: (Street)_________________________________________________________

(City)_____________________________ (State)_______________ (Zip)____________

Telephone:_________________________ Social Security # _______________________

Legal Name (Name listed on Birth Certificate or Government Issued ID):

_________________________________ Vacation Destination:____________________

Name of Agency:_________________________________________________________

Address: (Street)__________________________________________________________

(City)______________________________ (State)______________ (Zip)____________

Telephone:__________________________ E-Mail:______________________________

Agency Contact Person:________________________ Phone:______________________

Emergency Contact #1:_________________________ Phone:______________________

Relationship to Traveler:____________________________________________________

Emergency Contact #2:_________________________ Phone:______________________

Relationship to Traveler:____________________________________________________

Health Insurance- Primary (Type and #)_______________________________________

Health Insurance- Secondary (Type and #)_____________________________________

Allergies (List all known allergies):___________________________________________

History of Seizures? ______yes ________no

Describe any important medical information that would be needed in cases of emergency:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Traveler’s primary disability:________________________________________________

Other disabilities:_________________________________________________________

Is applicant fully ambulatory? YES q NO q

Indicate any mobility assistance required:______________________________________

Daily Living Skills Checklist: (Please check and provide details if needed)

Please provide details that will help staff members assist the traveler in above areas:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does applicant have any specific fears? (heights, elevators, animals, etc.) YES q NO q

If yes please explain fear, and how it is usually handled. ________________________________________________________________________________________________________________________________________________

Does applicant interact appropriately with:

Staff- YES q NO q

Peers- YES q NO q

Strangers- YES q NO q

If no, please explain:_______________________________________________________

________________________________________________________________________

Please list and explain any problem or unusual behaviors (wandering, fabricating stories, inappropriateness, etc.).

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please explain any additional information that will assist us in understanding your needs:

________________________________________________________________________________________________________________________________________________

Exceptional Vacations, L.L.C. is committed to providing a safe environment for all our travelers. We feel that a uniform medication policy is necessary to ensure the well being of all our vacationers. It is very important for all travelers to follow this policy. Our staff will assist any travelers requiring help with medication administration.

All medications need to be packaged prior to trip departure by the traveler’s family, pharmacist, or program. The following medication packaging options are available to our travelers:

Have the traveler’s pharmacist pre-package medications in blister packs. Blister packs must include the traveler’s name, medication name, dosage, and time medication is taken.

Pre-package medications in travel pillboxes. Pillboxes need to be clearly marked with the days and times the medication is to be taken.

Send medications in the original prescription bottle. Include details on dosage and time the medication is taken. (Extra Exceptional Vacation medication log sheets are available upon request).

Include an extra day of medications to allow for unexpected events such as spillage, transportation delays, etc.

Liquids, drops, creams, and inhalants should be sent in their original container with clear instructions.

A master list of all medications, dosages, and times of administration needs to be included with the traveler’s medication at time of trip departure.

All medications must be checked in with Exceptional Vacations staff at time of trip departure. Medications should be placed in a large manila envelope or small bag labeled with the travelers name. Medications should not be packed in the traveler’s luggage.

Special instructions regarding medications (i.e. blood glucose tests, blood pressure meters, meds that need to be refrigerated, etc.) need to be discussed with Exceptional Vacations prior to trip departure.

Any traveler who arrives with medications not packed according to these specifications may not be allowed to go on the trip. Please contact our office at 954-781-0990 with any questions regarding this medication policy.

Customers attending a vacation do so at their own risk, and release Exceptional Vacations, L.L.C. and it’s staff from liability for any harm to person or property that may occur. Customers who are removed from a trip for medical, behavioral, or psychological reasons are responsible for the cost of their return. Any incidental expenditures incurred by a traveler while on a trip are the responsibility of the traveler, and must be reimbursed to Exceptional Vacations, L.L.C. within 30 days of invoice receipt. Changes or cancellations made more than 30 days prior to trip departure will receive a refund less $50 cancellation charge and any pre-purchased portion of the vacation package. Changes or cancellations made 15-30 days prior to departure will receive a refund less $200 and any pre-purchased portion of the vacation package. Changes and cancellations within 14 days of departure are non-refundable. No shows, late arrivals to a departure site and refused boarding of a flight or cruise due to lack of proper identification are non-refundable. Exceptional Vacations, L.L.C. is granted permission to use trip photographs of a customer for promotional purposes. Receipt of this registration package implies understanding and agreement to these terms.

_______________________________________________ ____/____/____

Signature