Pre-Check In Form

It's Time to Check In For Your Vacation

Which Trip Is The Traveler Going On?

Have you travelled on a Special Journeys trip in the last year and is all of the previous pre-trip information the same?

Money

*Special Journeys must receive all monies at pickup. Consider using our spending money pre-payment option if staff will not be present at pickup and/or for travelers with food or diabetic issues who might purchase items they should not consume.

Special Shopping Notes (Specific items to buy, restrictions, etc.)(Required)

Medication

**We prefer but do not require a MAR. Attach to this form or send with medicine on trip.

Creams/Gels: Describe where "affected area" is located:

* if marked, provide frequency & baseline:

PRN's: Typical symptoms displayed; other info we might need:

Please call before sending multiple prescription pill bottles!

Prescription mouthwash and all liquids must be in a double zipper Ziploc® bag to avoid spills!

Address Information

Primary Contact Information

Phone Number of person who we contact if we have questions during the trip(Required)

If your agency has a 24x7 nursing contact, provide the phone number here:

Pickup Information

Pre-arrival phone call to:

Drop Off Information

Pre-arrival phone call to:

Updating Medical Information

List any additional allergies AND list if any of the above are no longer applicable:

Special Equipment description:(Required)

Provide information about any new or additional medical or care info since their last application. If you want to check what we have on file please call.

Pre-Trip Information Form