Passenger Information Form

Note: Documents must be in or .PDF format, photos must be in .JPG format, and files can not exceed 24MB in total file size.
All fields with an asterisk (*) are required.

*Tour Name:

*Tour Date(s):

*Traveler's Name:

*Traveler's Address:

*City:

*State:

*Zip:

*Traveler's Phone:

Cell Phone:

*Would you like to be contacted with additional information regarding Travel Insurance for this trip?
Yes No

If Yes, Please provide email address where we may contact you:

Billing Information

Name and/or Company Name:

Billing Address:

Traveler Identification

*Age:

*Date of Birth:

If you are a first time traveler with Progressive Travel please include a photo.

Upload Image:

Note: Photo must be in .JPG format and it, along with an optional Medication Document found further below, can not exceed 24MB in total file size.

*First Name:

Middle Initial:

*Last Name:

Multiple Day Trips

First Name:

Middle Initial:

Last Name:

Tour Contract

Emergency Medical Care Authorization

By signing this contract, I give permission for my assigned chaperone to proceed with emergency medical care and to sign necessary medical release forms. This permission is given with the understanding that the attending physician deems emergency medical attention is necessary. Progressive Travel, Inc. or a Chaperone will make every effort to reach the guardian prior to assuming the responsibility for signing a release for emergency medical treatment. This authorization will be used only in the event that the guardian cannot be reached.

By signing, I acknowledge that I understand and agree to the terms of the Progressive Travel, Inc. Special Tour Contract.

*Traveler (Signature):

*Date:

*Witness (Acknowledging the traveler has no guardian):

*Date:

*Guardian Signature (Required if Appointed):

*Date:

(If you are the traveler's guardian, please fill out section below)

*Guardian Name:

*Guardian Phone:

Photo Authorization Release

Yes, please feel free to use photos of this traveler taken on our tours for future Progressive Travel publications.

No, I do not wish photos of this traveler to be used for any future publications.

Participant Information

*Name:

Male

Female

*Phone:

*Shirt Size (For tours where we include a T-Shirt):

*Emergency Contact Person:

*Address:

*Day Phone:

*Night Phone:

*Physician's Name:

*Phone:

*Medical Assistance Number:

*Please list any special considerations that Progressive Travel, Inc., Special Tours should be aware of: (assistance needed, mobility needed, health needs, dietary restrictions, etc.)

OR Upload Medication Document:

Note: Document must be in or .PDF format and it, along with the optional Traveler Photo found further above, can not exceed 24MB in total file size.

It is mandatory that this information is as accurate and up to date as possible for the traveler for which this reservation is for.

**Any questions marked “yes” that need an explanation, please do so in the text area below it!

2. Tumors

Yes

3. Strokes

Yes

4. Seizures, Fainting Spells

Yes

5. Severe or Frequent Headaches

Yes

6. Thyroid Disease

Yes

7. Vision Problems

Yes

8. Contact Lenses

Yes

9. High Blood Pressure

Yes

10. Heart Problems/murmurs, etc.

Yes

11. Chest Pains/Difficulty Breathing

Yes

12. Asthma/Chronic Cough

Yes

13. Stomach/intestinal problems

Yes

14. Bladder/Kidney Problems

Yes

15. Cancer

Yes

16. Gout/Arthritis/Joint Pain

Yes

17. Bone/Muscular Problems

Yes

18. Allergies

Yes

19. Skin Diseases

Yes

20. Back Problems

Yes

21. Hearing Loss/Ear Problems

Yes

22. Is traveler a smoker?

Yes

23. Is traveler a first time flyer?

Yes

24. Does traveler know how to swim?

Yes

25. Does traveler have any fears?

Yes

26. Can traveler be given over the counter drugs such as Advil, Tylenol, etc.

Yes

27. Does the traveler use a walker, cane or wheelchair?

Yes

28. Does the traveler have problems walking long distances?

Yes

29. Is traveler able to handle his/her own money?

Yes

30. Does traveler have any bladder/bowel control concerns?

Yes

31. Is traveler able to take care of their bathroom needs on their own?

Yes

32. Any other information?

Yes

33. Are there any restrictions on what can or cannot be purchased while on the tour? If yes, please provide details:

Yes

I, have filled this form out to the best of my knowledge.

My relationship to this traveler is (Case Manager, Guardian, etc.).

Miles of SmilesProgressive Travel Specialty Tours