Vacation Questionnaire – Time to Split

Today's Date*
Date Format: MM slash DD slash YYYY
How did you hear about Time to Split?*
Full Name*
First Middle Last
Email
Main Phone Number*
Preferred Method of Communication*
- Email
- Phone Call
- Text
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of Seniors (55+)*
Number of Adults (18+)*
Number of Youths (Under 17 years)*
Special Circumstances I need to consider...*
- Mobility Issues need to be considered
- Special Dietary requirements to be considered
- Someone in the group is Active Military, Retired Military, Fire, EMS or Police
- Someone in the group is pregnant
- None of the above

Passports*
- Everyone in our group have valid passports that will expire more than 6 months after travel date
- Some people in our group have valid passports that will expire more than 6 months after travel date
- No one have a passport.
- I am not sure.
- This is a domestic trip; no passport needed.
Travelers' Information*
Please add a line for each traveler in your group, exactly written on their passport or government ID. This information is required to generate accurate quotes from most suppliers. I must have complete information for all travelers in your group. If you are not comfortable providing this, please call me to discuss. I will not be able to proceed without this key information.
First Name Middle Name Last Name Date of Birth
Would your group want to include travel insurance/protection?*
- Yes
- No
*Travel Insurance is highly recommended to cover the unpredictable circumstances your group may face. If your group denies insurance, I will email you with a travel insurance waiver that must be signed*

First Choice	Second Choice	Third Choice

First Name	Middle Name	Last Name	Date of Birth