PRM Declaration - Adria Airways

Declaration of disabled person or person withreduced mobility (PRM) traveling by airA. Passenger booking detailsName of passenger with special requirements:Contact phone number:Booking reference:E-mail:Outbound flightnumber & date:Inbound (return) flightnumber & date:B. General disability descriptionB1. How would you shortly describe your disability?Note: It may also be helpful to give the medical term for the disability.C. MobilityC1. Do you have any kind of mobility difficulty? Yes / NoC2. Can you manage to orientate yourselves atthe airport on your own, without assistance? Yes / NoC3. Are you taking your own wheelchair? Yes / NoC3 (a) If Yes, is it battery operated? Yes / NoC3 (b) If Yes, are batteries type of:i) Dry Cell Yes / Noii) Wet Cell Yes / NoNote: although you may not need assistance all the timesome distances at the airport terminal can be long –between the airline check-in desk and the departure gate.Note for booking agent:If yes, booking either as WCMP, WCBD or WCBW isrequired.Note: Due to very high risk of possible damage toelectronic equipment or control mechanism, batteryoperated wheelchair will only be accepted if possible toload/unload it in upright position.Note for booking agent:If yes, booking as WCBD is required.If yes, booking as WCBW is required.Note: Battery wet is considered as dangerous goods andis not accepted on JP operated flights.C3 (c) Is your wheelchair foldable? Yes / NoC3 (d) Enter dimensions and weight of your wheelchair?While opened:Width (cm) x Height (cm) x Depth (cm)Weight: _________ kgsWhile closed (folded-up):Width (cm) x Height (cm) x Depth (cm)OBB2N06_ang / Rev: 2 / Valid from: 18NOV09Page 1 of 2

D. Self-sufficiencyD1. Do you need to borrow a wheelchair at theairport for distances to/from the aircraft? Yes / NoD2. Do you need assistance to walk up/down theaircraft steps? Yes / NoNote: These can be steps with narrow treads.D3. Do you require an assistance to visit toiletfacilities on board the aircraft? Yes / NoD4. Do you consider yourself to be selfsufficient? Yes / NoNote for booking agent:If yes, booking as WCHR may be required.Note for booking agent:If yes, booking as WCHS may be required.Note for booking agent:If yes, booking as WCHC and escort may be required.We do not provide on-board wheelchair.IMPORTANT:If Yes, please read note below.NOTE about self-sufficiency:In case passenger claims to be self-sufficient and able to travel alone (without escort), such passenger shall becapable of:• breathing without additional oxygen (meaning passenger should not be reliant on supplementary oxygen);• feeding (meaning passenger should be capable of feeding themselves);• lifting (meaning passenger should be capable of moving from a passenger seat to an on-board wheelchair ifavailable);• communicating (meaning passenger should be able to communicate with cabin crew and understand theiradvice and instructions);• toileting (meaning passenger should be capable of using the toilet facilities unaided);• medicating (meaning passenger should be capable of administering their own medicines and medicalprocedures).Passenger shall never claim that he/she is self-sufficient if he/she is not since this may cause him/her and theairline/airport staff serious problems because they will be unable to meet their basic needs.This declaration shall be signed and sent to booking agent making reservation on behalf of passenger(alternatively to Adria Airways fax: +386 4 25 94 573) as soon as possible, latest 48 hours beforescheduled departure in order to confirm booking.Availability and confirmation of booking is subject to free seat on board selected flights as well as otheroperational & safety limitations (max.number of PRM on board, size of aircraft and its doors,…).I confirm that the informati on given o n this form is correct and u nderstand that there is no gu arantee that theseneeds will be met.I also u nderstand and agree that this i nformation will be passed on to tho se people responsible for s upplying allthe arrangements for my travel with Adria Airways and other carriers, as the case may be.I state that I gave this information voluntarily.Place and date ______________________ Passenger signature/date ________________________-------------------------------------------------------------------------------------------------------------------------------------------------------------------------NOTE: If you are answering the above questions on behalf of a disabled person please sign below to confirm thatthis information is accurate a nd that you have the disa bled person’s permission to p ass it on for the purpose ofmaking travel arrangements.Place and date ______________________Signature/date _________________________________OBB2N06_ang / Rev: 2 / Valid from: 18NOV09Page 2 of 2