Anderson Travel and Tours

Medical Form – Motorcoach Tours

Please enable JavaScript in your browser to complete this form.
Guest Name
(phone you will have with you on the tour)
“DO NOT” LIST YOUR SPOUSE OR PARTNER who will be traveling with you! This MUST be a contact who will not be on this tour/motorcoach!
(spouse, child, other relative, guardian, friend, etc.)
Emergency Contact's Address:
EXAMPLES: pacemaker, ostomy, asthma, diabetes-insulin, epilepsy, cancer, recent surgery, bleeding disorder, taking blood thinner, etc.
EXAMPLES: food allergies, drug allergies, latex allergy, other allergies, insect stings, or anything else that could cause an allergic reaction leading to anaphylactic shock.
Do you have a DNR (Do-not-resuscitate) Order?
(In case of emergency)
(look on the back of your insurance card)
NOTE: All required fields with a red asterisk beside them must be completed before this form will submit.