EmailMe Form - Sundial Special Vacations Traveler Profile

Name exactly as it appears on government issued ID *

First Middle Last

Preferred Name

Date of Birth *

MM / DD / YYYY

Sex *

Male

Female

Traveler Email *

If traveler has no email please list care giver's email.

Mailing Address (Where you would like your package to be mailed to.) *

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

Phone *

### - ### - ####

24 HR Emergency Contact Person *

First Last

This person listed MUST be able to immediately assist with important information

24 HR Emergency Contact Person Phone # *

### - ### - ####

Care Provider/Agency Name *

Care Provider/Agency Mailing Address *

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

Care Provider Email *

Physicians Name *

Physician Phone # *

### - ### - ####

Can Vacationer Travel Alone by Air? *

Yes

No

If "No" is answered please explain in box below.

Please explain specific needs if vacationer is unable to travel alone by air.

Is traveler confined to a wheel chair? *

Yes

No

If yes, please call our office.

Please tell us all about yourself (eg. I smoke, I like to swim, I tire easily) *

Please include anything that our Tour Guides should know.

Please upload a copy of a valid State or Federally Issued ID such as ID Card, Passport, Drivers License *

If traveling on cruise or international vacations, a passport is mandatory.

Please upload a CLEAR & CURRENT photo *

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