Kristy’s Client Intake Form
Customer Details:
Full Name Passenger #1
*
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Do you have Mobility needs?
Wheelchair
Scooter
Other
Passenger # 2 Full Name
First Name
Middle Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Anyone else traveling with you? Name & Date of Birth
Do you have Mobility needs?
Wheelchair
Scooter
Other
Please Put in dimensions of Scooter/Wheelchair
Please tell me your favorite kind of travel, preferred dates, what is important to you
Questionaire
Rows
Yes
no
Did you serve in military
Are you first responder
Teacher
Do you have food allergies
Is there anything that can make travel easier for you
Do you have current passport with 6 months expiration date from cruise date
Have any special needs
Please give detail to anything you said yes to above
Please select your interested travel
Hotel
Car
Flight
Cruise
All Inclusive
Land Tour
Please select the best time to contact you
Mornings
Afternoon
Evenings
Please select the best method of communication
Call
Text
Email
Why are you traveling
Work
Fun
Birthday
Wedding/Anniversary
Submit
Should be Empty: