Application Form – Special Needs
1
Applicant
First name:
Last name:
Travel agency:
Street, No.:
Postcode:
City/Country:
Tel.:
Fax:
Email:
Tour operator:
2
Booking number:
Disabled passenger
First name:
Last name:
Age:
Title:
First name:
Last name:
Age:
Title:
First name:
Last name:
Age:
Title:
First name:
Last name:
Age:
Title:
3
Companions
Further passengers please mention in the remarks.
4
5
Flight Details
Outbound
Date:
Flight No.:
from:
to:
Inbound
Date:
Flight No.:
from:
to:
Special Need
MAAS: Assistance generally
ASR: Seat reservation*
Please notify the degree of disability:
Companian is included in WCHR/WCHS/WCHC services.
* Seat reservations are free of charge for holders of a disabled pass and 1 companion.
For reasons of safety following seats cannot be given to disabled, limited mobile or ill passengers: Mother-child row (1st row)/Emergency exit.
Disability level of passenger
Walking impaired
BLND: Visually impaired
DPNA: Mentally handicapped
DEAF: Hearing impaired
DEAF/MUTE: Hearing-speech impaired
Other:
Information related to the handicap please mention in the remarks.
Wheelchair assistance
WCHR: Walking impaired passenger
Needs help within the airport building to/from
the aircraft, can use a ramp bus and can anscend/
descend stairs, needs no help in the cabin to/from
seat and toilet.
WCHS: Severe walking impaired passenger
Needs help within the airport building to/from the
aircraft, cannot use a ramp bus and cannot ascend/
descend stairs, needs no help in the cabin to/from
seat and toilet.
WCHC: Immobile passenger
Needs help within the airport building to/from the aircraft,
cannot use a ramp bus and cannot ascend/descend stairs,
can use passenger seat with back in upright position,
is unable to cover distances unassisted; e.g. paraplegia,
hemiplegia, multiplesclerosis etc.
Wheelchair of passenger other mobility aids please mention in the remarks with weight and dimensions.
WCMP: Wheelchair manual power
WCBD: Wheelchair battery-powered
Collapsible:
Yes
only with non-spillable dry cell/gel type battery.
Battery must be disconnected and battery terminals
insulated.
Dimensions in cm:
No
Depth:
Width:
Height:
Weight:
kg
AYT SP-T/SR F002-06 EN 06/12
If the provided wheelchair at the airport does not meet the special disability and the local circumstances and regulations allows, the disabled guest can use its own
wheelchair up to the aircraft. The wheelchair is taken over and loaded then from the loading staff. At the destination airport the wheelchair is provided again at the aircraft.
6
Medical XBAG (Excess baggage)
Dimensions in cm:
Baggage type:
Depth:
Contents:
Weight:
Width:
Height:
kg
Remarks
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