Vaya con Silla de Ruedas: Client Information Form

Paratransit Tour Service in Costa Rica

Vaya con Silla de Ruedas, S.A.
"Go with Wheelchairs"
Tel/Fax: (506) 2454-2810 / Cell (506) 83915045
email: vayacon@racsa.co.cr
www.gowithwheelchairs.com

Client Information Form

ALL INFORMATION WILL BE KEPT CONFIDENTIAL

Name

Address
City
State
Zip

Phone
E-mail Address

Date of Birth
Sex
Height
Weight

Occupation

Specific instructions regarding your arrival:

Type of Disability:

PLEASE CIRCLE ALL THAT MAY APPLY:

A. Ambulatory with wheelchair.

B. Ambulatory with aides, e.g. crutches, cane, walker, or other:

C. Non-ambulatory with wheelchair:

D. Type of wheelchair, e.g. manual, electric, scooter or other:
Dimensions: Width____________Length____________Weight____________

E. Visually impaired

F. Hearing impaired

G. Speech disorder

H. Mentally challenged or illness. Please explain degree:

I. Communicable or related diseases. Please describe:

J. Prescribed medications. Please describe:

Will you require an aide or any other special assistance when traveling with our service?
Yes__ No__
If yes please give any other information that maybe of help to our staff in order to serve your needs:

Important Facts and Company Policies
Client Information Form
Vaya en Silla de Ruedas, S.A.: General Release of Liability
Questionnaire

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