01582 765 423info@jumbulance.org.uk

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Jumbulance Trust | Accessible holidays and travel in the UK and Europe

Providing accessible holidays and travel in part coach, part ambulances. Available to hire for disabled, elderly & severely ill passengers.

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Traveler Application

Traveler Application

07483 414330

info@jumbulance.org.uk

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Donate Now

Home
About Us
Holidays & Day Trips
Hire A Jumbulance
- How Travel Works
- Jumbulance Features
Volunteer
Support Us
- Support Us
- Make a Donation
Contact Us

Home
About Us
Holidays & Day Trips
Hire A Jumbulance
- How Travel Works
- Jumbulance Features
Volunteer
Support Us
- Support Us
- Make a Donation
Contact Us

Traveler Application Form

Destination

Departure Date

Personal Details (Please answer ALL questions)

First Name

Last Name

Date of Birth

Your Address (Including Postcode)

Home Telephone

Mobile Telephone

Email Address

Next of Kin

Full Name

Relationship

Their Address (Including Postcode)

Emergency Telephone

Their Email Address

Your Doctor's Contact Information

Doctor's First Name

Doctor's Last Name

Surgery Address (Including Postcode)

Doctor's Telephone

Passport & Health Card (This is required for European travel)

Passport Number

Passport Date of Expiry

EHIC Card Number

EHIC Date of Expiry

Insurance Provided by The Jumbulance Trust

Yes No

*If you have your own insurance please provide the following details:

Insurance Provider

Policy Number

Medical Information

If you have a Care Plan please provide a copy Note: If there is any change in your medical condition or medication prior to travelling, then please inform the Group Leader or the Jumbulance Office .

Medical Conditions

Past Operations

Your Height

Your Weight

Are you a Diabetic?

Yes No

If Yes, how is this controlled?

Do you have a pacemaker?

Yes No

Do you suffer from epilepsy?

Yes No

If Yes, please provide more details – symptoms, treatment, etc. When was your last attack?

Do you suffer with memory loss?

Yes No

Please specify other medical conditions requiring injections or special treatment

Mobility

Are you able to stand?

Yes No

Are you able to walk?

Yes No

Are you able to manage stairs?

Yes No

Do you use a wheelchair?

Yes No

Do you have your own wheelchair?

Yes No

If yes, is it collapsible?

Yes No

Manual or Electric Wheelchair? (If Electric chair please contact the group organiser)

Manual Electric

Wheelchair Width (Open)

Wheelchair Width (Closed)

Wheelchair Height (Open)

Wheelchair Height (Closed)

Wheelchair Depth (Open)

Wheelchair Depth (Closed)

Wheelchair Weight (KG)

Specify aids used, eg, walking stick, zimmer frame, etc.

Do you need a hoist for transferring? (please bring your own slings)

Yes No

Communication

Sight

Visual Aids

Hearing

Hearing Aids

Speech

*Please specify restriction and aids used, eg. Boards, cards, etc.

Breathing

Do you use inhalers?

Yes No

Do you use a nebuliser? (If yes, please bring your own)

Yes No

Do you need oxygen? (If used frequently, please bring your own supply which must be ordered in advance)

Yes No

Personal Hygiene

Independent with personal care?

Yes No

Do you need assistance with washing?

Yes No

Do you need assistance with dressing?

Yes No

Are you continent?

Yes No

Do you use pads? (If yes, please bring your own)

Yes No

Do you have a catheter? If yes, please bring a spare

Yes No

If you have a catheter, when was it last changed?

Do you use a bottle? (Please bring your own)

Yes No

Do you use a bedpan?

Yes No

Do you use a commode?

Yes No

Do you have any current sore areas or wounds? (If yes, please bring 10 days’ supply of dressings)

Yes No

Nutrition

Special Diet

Do you have any specific diet requests?

Do you need assistance with feeding?

Yes No

Do you need assistance with drinking?

Yes No

Are any aids or appliances used? (Please bring special cups, straw, rimmed plate, etc.)

Yes No

Are you fed by a gastric tube? (If YES Please bring at least 10 days’ supply)

Yes No

Night Time

Do you need any help during the night?

Yes No

Allergies

Any known allergies?

Yes No

Any known drug sensitivities?

Yes No

If yes to either of the above please provide more details such as reaction, treatment, etc

Medication

IMPORTANT – PLEASE LIST ALL MEDICATION AND ATTACHED CHEMIST’S PRINT OUT AND BRING 10 DAYS SUPPLY OF MEDICATION AND DRESSINGS WITH YOU. If any of the above medication information should change before the date of travel please inform your group leader as soon as possible. Failure to complete this section properly will result in you being refused travel. .

Are you self-medicating?

Yes No

Medicine Name

Dosage

Frequency

Medicine Name

Dosage

Frequency

Medicine Name

Dosage

Frequency

Medicine Name

Dosage

Frequency

Medicine Name

Dosage

Frequency

Medicine Name

Dosage

Frequency

Medicine Name

Dosage

Frequency

Medicine Name

Dosage

Frequency

Medicine Name

Dosage

Frequency

Medicine Name

Dosage

Frequency

General Information & Declaration

Is this your first Jumbulance trip?

Yes No

If not, how many times have you travelled?

Photograph / video consent*
Do you give permission for photos and video of you to be reproduced for the purposes of promotion?

Conditions of use - We will not use the photographs/film for any other purposes than those mentioned above. - We will not include personal details (such as postal addresses, or telephone number) on our website, printed materials or other marketing/promotional materials. - Copyright of photographs taken will remain with the property of Jumbulance Trust. Images will be held by the Jumbulance Trust for a minimum of 10 years. *Full consent form available if required

Yes No

Are you a smoker?
The Jumbulance Trust has a strict no smoking policy (and drinking alcohol is not permitted) on the vehicle

Yes No

Please tick to confirm that you have seen and understood our Child & Vulnerable Adult Policy

Yes No

I confirm that the above information is correct and authorise the Jumbulance Trust or its representatives to seek confirmation from my Doctor if required. For insurance purposes I also confirm: That I am not travelling against the advice of a medical practitioner nor for the purpose of obtaining medical treatment abroad. That I am not expecting to give birth before or within eight weeks following the date of arriving home The group leader/s and/or Jumbulance Trust do not accept and you hereby release each of them from all and any liability or obligation to pay to you any compensation, costs or damages for any loss which you may incur a) as a result of any changes or delays in to the holiday arrangements and/or b) or for any damage or injury caused to you or any group member during the holiday howsoever arising.

If completing electronically please check this box to confirm you have read, understand and agree to the above

The Jumbulance Trust Charity Number: 1090731 | Call Us: 07483 414330 | info@jumbulance.org.uk

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