About the Traveler
Please note:
If a traveler must be sent home early due to disruptive or aggressive behavior, or is refused boarding by an airline or cruise ship due to lack of valid identification, this will occur at the traveler's expense and without refund.
Please consider this carefully before signing up for a tour.
Thank you.
Trip name and code # that you want to register for
Traveler's (Legal) FIRST Name
We need their legal name that is on their photo I.D.
LAST Name
Middle Name
What name does the traveler like to be called?
example: Bill, Buddy, Susie, etc.
Birthdate
please write the year as four digits, example: 1975 or 2007
Sex
Male
Female
Eye Color
Please select...
Brown
Blue
Green
Hazel
Grey
Hair Color
Please select...
Brown
Blonde
Black
Red
Grey
Bald
Height
Weight
T-shirt Size
Please select...
Small
Medium
Large
X - large
2X - large
3X - large
Traveler Requires a:
1:4 ratio
1:1 ratio (there is an additional charge for 1:1)
Please explain why a 1:1 ratio is needed.
Living Situation
Group Home
Lives with Family
Supportive Living
ICF / Residential Facility
Lives Independently
For statistical use only
(optional
): Ethnicity of traveler
is:
White
Black
Hispanic
Asian
Other
First time traveling with New Directions?
Yes
No
How did you hear about New Directions?
Please select...
Regional Center
Recommended by someone
Website
Facebook
At a presentation by New Directions
Other
Current State Issued Identification?
(required for flying)
Yes
No
Current Passport?
(required for cruises and international)
Yes
No
Preferred Airports
Can Traveler Fly Alone if a Tour Guide is at the Gate in LAX to Meet Them?
Yes
No
Please explain why the traveler cannot fly alone.
COGNITIVE / MENTAL INFORMATION
Cognitive Level
Mild Intellectual Disability
Moderate Intellectual Disability
Profound / Severe Intellectual Disability
Autism
Yes
No
Down Syndrome
Yes
No
Cerebral Palsy
Yes
No
Mental Illness
Yes
No
Please give more cognitive/mental details if needed.
Food Allergies
Drug Allergies
DIABETES INFORMATION
Does the traveler have diabetes?
Yes
No
Medication Controlled
Yes
No
Insulin Controlled
Yes
No
Can the traveler give their own insulin injections?
Yes
No
Diet Controlled
Yes
No
Dietary Restrictions and Guidelines
Tests own blood
Yes
No
Will the traveler bring their own blood testing kit?
Yes
No
SEIZURE INFORMATION
Does the traveler have seizures?
Yes
No
Seizures are controlled
Seizures are uncontrolled
Date of Last Seizure
SELECT ALL THAT APPLY
Vision
Vision is okay
Partially blind
No vision at all
Hearing Level
Hearing is okay
Partial hearing
No hearing at all
Does the traveler wear hearing aids?
Yes
No
Communication
Verbal
Non-verbal
MOBILITY INFORMATION
Edit this text
Mobility is okay
Traveler has mobility issues
Walks slowly
Yes
No
Uses a walker
Yes
No
Needs a wheelchair only for distance
Yes
No
Does the traveler use a wheelchair on a regular basis?
Yes
No
Uses a manual wheelchair
Yes
No
Is the wheelchair collapsible?
Yes
No
Uses a power chair
Yes
No
Needs a lift van
Yes
No
Needs a Hoyer lift
Yes
No
Brings own Hoyer lift
Yes
No
Can traveler bear weight?
Yes
No
Does traveler need to be lifted for transfer?
Yes
No
Traveler's Behavior
If a traveler must be sent home early due to disruptive or aggressive behavior, this will occur at the traveler's expense and without refund.
Please consider this carefully before signing up for a tour.
Does the traveler have a history of aggression, disruptive, or inappropriate behavior?
Yes
No
Description of aggression, disruptive, or inappropriate behavior
Known Fears (i.e. dogs, heights, escalators, etc.)
Traveler's Self Care
Dressing
Totally Independent
Verbal Prompt Needed
Physical Assist Needed
Both Verbal & Physical Assist Needed
Describe Dressing Support Needed
Bathing
Totally Independent
Verbal
Prompt Needed
Physical Assist Needed
Both Verbal & Physical Assist Needed
Describe Bathing Support Needed
Feeding
Totally Independent
Verbal
Prompt Needed
Physical Assist Needed
Both Verbal & Physical Assist Needed
Describe Feeding Support Needed
Traveler's Self Care
Hygiene
Totally Independent
Verbal Prompt Needed
Physical Assist needed
Both Verbal & Physical Assist Needed
Describe Hygiene Support Needed
Toileting
Totally Independent
Verbal Prompt Needed
Physical Assist needed
Both Verbal & Physical Assist Needed
Describe Toileting Support Needed
Wears adult briefs
Yes
No
Needs sheet protection
Yes
No
Wears a condom catheter
Yes
No
Swimming Ability
Is the traveler okay to use a hot tub?
Swims well
Shallow end only
Cannot swim at all
Yes
No
Do not know
Safety Skills
Traveler will stay with the group
Traveler has a tendency to wander
Money Skills
Tour guide should hold the traveler's spending money
Traveler may hold their own spending money
Is the traveler able to read?
Yes
No
Traveler knows how to use a phone.
Yes
No
Does the traveler smoke?
Yes
No
May the traveler consume alcoholic beverages?
Yes
No
At a theme park, does the traveler:
Likes all rides
Likes fast rides only
Likes slow rides only
Does not like any rides at all
Do not know
Sleeping Habits
Sleeps soundly
Yes
No
Gets up often at night
Yes
No
Snores loudly
Yes
No
May share a room with another traveler (2 beds per room)
Yes
No
Must share a room with a tour guide
Yes
No
If the traveler must room with a tour guide, please explain the reason why.
Prefers to have their own room (there will be an additional fee for a single room)
Yes
No
Describe any other information we should know about the traveler.
Traveler's Address
Address
City
State or Province
Please select...
CA
AL
AK
AZ
AR
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip Code
Country
Please select...
United States
Canada
Mexico
Other
Traveler's Home Phone
Traveler's Cell Phone
Traveler's Email
leave blank if you do not have an email
Traveler Billing Contact
Contact's First Name
Contact's Last Name
Is this contact a Regional Center Case Manager?
Yes
No
Regional Center
Relationship to Traveler
Email
Street Address
City
State or Province
Please select...
CA
AL
AK
AZ
AR
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip Code
Country
Please select...
United States
Canada
Mexico
Other
Cell Phone
Home Phone
Work Phone
Additional Traveler Contact Roles
Billing Contact is also a...
Travel Day Contact
Tour Information Mailing Contact
Regional Center Case Manager
Family Member
Billing Contact - Who do we send invoices, statements, etc? Travel Day Contact - Who do we contact on the first and last day of the tour for travel related issues? Mailing Contact - Who do we send the traveler's itinerary, packing list, name badge, etc?
Who will be the contact person on the first and last day of the tour for travel related issues?
Travel Day Contact
First Name
Last Name
Is this contact a Regional Center Case Manager?
Yes
No
Regional Center
Relationship to Traveler
Email
Street Address
City
State or Province
Please select...
CA
AL
AK
AZ
AR
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip Code
Country
Please select...
United States
Canada
Mexico
Other
Cell Phone
Home Phone
Work Phone
Travel Day Contact is also a...
Tour Information Mailing Contact
(will
receive the traveler's itinerary, flight info, packing list, name badge, etc
Regional Center Case Manager
Family Member
Who would you like to receive the traveler's itinerary, flight info, packing list, name badge, etc?
Travel Information Mailing Contact
First Name
Last Name
Is this contact a Regional Center Case Manager?
Yes
No
Regional Center
Relationship to Traveler
Email
Street Address
City
State or Province
Please select...
CA
AL
AK
AZ
AR
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip Code
Country
Please select...
United States
Canada
Mexico
Other
Cell Phone
Home Phone
Work Phone
Travel Information Mailing Contact is also a...
Regional Center Case Manager
Family Member
Do we have all the roles?
Tour Payment -
please note that the Traveler
is not officially on the tour
until we receive
at least a 25% deposit
and the registration form is approved.
Tour Cost
Are you signing up for more than one trip? Enter any additional tour #'s and names here.
Payment Options -
please note that the Traveler
is not officially on the tour
until we receive
at least a 25% deposit
Please select...
I will be sending a check to New Directions
Regional Center will be sending a check to New Directions
Please email me an invoice
Please send me an invoice by regular mail
Please apply Undesignated Funds towards this trip
I will be calling to make a credit card payment over the phone
I will be applying for a scholarship
Name of person completing this form
Contact phone in case we have any questions
Payment Options
Pay Online Now
Pay Later
Payment Options
Please select...
Pay in Full
Deposit (25% recommended, $50 minimum)
Online Payment Information
Deposit Amount
Name on Card
Card Number
Month
Year
Code
Billing Email
Need assistance with this form?
