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2006 Quacker Cruise

2003 Quacker Cruise

About the Quacker Factory

About Cruise Everything

Past Guest Comments

SPECIAL NEEDS FORM
Quacker Cruise and Quacker Vacations

This form needs to be completed by any guest with special needs such as dietary and physical needs. Please note read the Terms and Conditions before submitting this form.

Click Here to View the Terms and Conditions!

* Required fields

Name *

E-mail Address *

CRUISE EVERYTHING (Five Digit) RESERVATION NUMBER (Located on Cruise Everything Invoice at upper left corner). Leave blank if you just submitted your Reservation Request Form and have not been assigned a Reservation Number.

Daytime Telephone (With Area Code): *

Evening Telephone Number (With Area Code):

Address *

Address:

City:

State: *

Zip Code: *

Please Describe Special Needs: *

Check Here if you are a guest with Dietary Needs such as Vegetarian or Kosher. If yes, page down for additional information.

Check Here if you have Severe Allergies. If yes, please page down for additional information.

Check Here if you have Diabetes. If yes, page down for additional details.

Check Here if you have Respiratory Needs. If yes, page down for additional information.

Check Here if you require the assistance of a Service Animal. If yes, page down for additional details.

Check Here if you are a guest with Mobility Needs:

I can step up onto a bus?
Yes
No, I need a hydraulic lift equipped vehicle for tours or transfers.

Check here if you can walk small distances.

Are you bringing a wheelchair or scooter?
Yes, a wheelchair.
Yes, a scooter.
No, I don't need one.
No, I but I will need to rent a chair or scooter.

If you are bringing a wheelchair or other mobility aide, what type?
Fold-up wheelchair
Electric wheelchair
Scooter
Walker

If you will need to rent a wheelchair or electric scooter, and would like to add this rental to your vacation package, please indicate the type you would like:

Please list any additional mobility needs:

GUESTS WITH SEVERE ALLERGIES: Are your allergies food related?
Yes
No

Do you carry an EpiPen for emergencies related to allergies?
Yes
No

Please list your allergies or any additional allergy related needs:

GUESTS WITH DIABETES: My diabetes is controlled through:
Medications
Diet (as noted below)
Both

Check Here if you require access to refrigerated medicine.

Check Here if you need Hypodermic Disposal Facilities.

Please list all medications and any additional diabetic needs:

GUESTS WITH RESPIRATORY NEEDS: Do you require the use of oxygen?
Yes
No

Are you bringing a CPAP machine?
Yes
No

Please list any additional respiratory needs:

GUESTS WITH A SERVICE ANIMAL: Will you be bringing a service animal?
Yes
No

If yes, what type of service animal?

Please list any additional service animal needs:

GUESTS WITH DIETARY NEEDS such as Vegetarian or Kosher, please list dietary needs:

Check here if you would like the Vegetarian option at all meals.

ADDTIONAL OR OTHER CONDITIONS: Please describe any condition, illness, equipment or facillities that require special needs that may not have been listed above:

I understand the Terms and Conditions of this vacation (Please see link below for additional details). *

I have read and agree to the Privacy Policy *

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Please note the following items before submitting this form:

Complimentary wheelchairs are not available. If you wish to add a wheelchair or scooter rental to your vacation package, please indicate your choice in the appropriate field above in the Special Needs form.
Persons requiring oxygen must either make independent arrangements for thier oxygen needs or bring there own.
Service animals must have all required immunizations and paperwork.
Persons undergoing CAPD (Peritoneal Dialysis) must arrange for delivery of their own solutions and supplies.

TRAVELERS WITH SPECIAL NEEDS
Cruise Everything, Quacker Vacations, Quacker Factory and Fritz Travel, Inc. will make reasonable efforts to accommodate the special needs of tour participants. It is strongly recommended that persons requiring assistance be accompanied by a companion who is capable of and totally responsible for providing the assistance. Neither Cruise Everything, Quacker Vacations, Quacker Factory, Fritz Travel, Inc., vendors related to this trip, personnel nor its suppliers may physically lift or assist clients onto transportation vehicles. Travelers needing special assistance for other than personal needs must inform us at the time of booking to determine what assistance may reasonably be made available by Quacker Vacations. We regret that we cannot provide special individual assistance to a tour member with special needs for walking, dining or other routine activities.

Click Here to View the Terms and Conditions!

If you are unable to complete this form, please call (646) 383-7196 or (800) 283-9577.

Reservation Hotline
(239) 275-1717
Monday - Friday, 9:00am to 5:30pm Eastern
Reservations and Event Management by Cruise Everything
1950 Courtney Drive, Suite 1, Fort Myers, FL 33901
Copyright ©2010, Quacker Cruise, Quacker Vacations and Cruise Everything. All rights reserved.
Vacation itinerary, events, shows, celebrities, Quacker Factory participation, amenities and gifts are subject to change.
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