PRiSM Study

PRiSM Study
PLEASE ALLOW 2 BUSINESS DAYS FOR A REPLY
Visit Start Date

MonthDayYear
Visit End Date

MonthDayYear
Visit Location
AUTHORIZED STUDY PARTNER

The Authorized Study Partner is a non-participating travel companion assisting the Study Participant.

Study Partner Name -must match government ID that will presented to TSA appears
Study Partner Last Name* / First Name* Middle Name
Study Partner Birth Date

MonthDayYear
Study Partner Gender (as it appears on your Passport or Government Issued ID)
Study Partner Companion Phone
617-720-6100
Study Partner Companion Email
example@example.com
Study Partner Companion GOES/TSA Pre-Check/Known Traveler Number
Study Partner Companion Redress Control Number (redress number) if applicable
Study Partner Companion Frequent Flyer Numbers
*Please indicate Preferred Airlines followed by your FF number, in order of preference
Study Participant/ Study Partner Companion Special Needs/requests
*Please list any special needs requests or air or car preferences
Preferred Form of Communication
STUDY PARTICIPANT INFORMATION

The following information is required for TSA compliance, Great Getaways internal records and reservation ticketing.

Study Participant Name- Must match government ID that will presented to TSA
Participant Last Name* / First Name* Middle Name
Birth Date

MonthDayYear
Gender (as it appears on your Passport or Government Issued ID)
Gender must match Government ID
TSA Pre✔ Known Traveler Number (KTN) GOES if applicable
Redress Control Number (redress number) if applicable
Do you need a train reservation?
- Please provide train reservation dates and preferences
- Do you need a flight reservation?
- AIR TRAVEL REQUEST
- Departure Airport City
- Departure Date
  
  MonthDayYear
  Date
- Return Date
  
  MonthDayYear
  Date
- Preferred Departure Time
  
  :HourMinutesAM/PM Option
- Preferred Return Time
  
  :HourMinutesAM/PM Option
- If you have preffered flights:
  Please list them above
- Seating Preference (seating not guaranteed)
- Frequent Flyer Numbers
  *If you have a frequent flyer account, please list here.
- Accessibility, special needs requirements, air and hotel preferences, and requests?
  *Please list any special needs requests or preferences
- Do you require hotel accommodations?
- Name to use for the room reservation (adult name).
  
  First NameLast Name
- Room/Bedding Type*not guaranteed
  *Please select which bed/room type you prefer.
- Special Requests
  *Please list any special requests you may have.
- Anything else you'd like us to know?
  *Please indicate any other travel needs, details, health concerns or special requests for this trip.
- Click the Box
- Privacy Notice and Consent- In the course of providing travel services, Great GetAways may collect, store, use, disclose, and transmit your personal information. This may include, but is not limited to your full name, address, contact details, date of birth, identification numbers, travel preferences, demographic information, and specific travel or hotel requests. This information is required to arrange your travel and related services. Your information may be shared with third parties—event organizers, planners, affiliated organizations, and travel or lodging provider as needed to fulfill your travel arrangements. By checking the box below, you authorize Great GetAways to collect, use, disclose, and transmit your personal information as outlined above. If you submit this information on behalf of others, you confirm that you have the legal authority to do so and consent to the use of their information for these purposes. Your information will be handled securely and shared only as necessary. If you wish to review, update, or manage your information, please contact us at travel@ggatravel.com.
- For questions please email travel@ggatravel.com or call 617-720-6100 weekdays 10:00 am- 4:00 pm eastern standard time.
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