NAME:  _____________________________________________________      LOCAL NO:  ___________

1.             I will be travelling to Regional Educational School by:

                OWN VEHICLE o       WITH SOMEONE ELSE o         OTHER o

2.             I can transport someone:  YES o                    NO o

3.             Will you be bringing your family?      Spouse -               YES o      NO o

                                                                                Children -              YES o      NO o     How many? ______

4.             Will your attendant care provider require accommodation?       YES o                    NO o

5.             SPECIAL NEEDS:

                PLEASE BE SURE TO LET THE HOTEL KNOW IF YOU REQUIRE ANY OF THE FOLLOWING:

                Please check any of the following which affects you:

                o  Special Diet                                                                    o  Blind or Visually Impaired

                o  Wheelchair                                                                      o  Deaf or Hearing Impaired

                (Hub to hub measures _____ inches)                           o  Crutches

                o  Other (please specify)  _________________________________________________________

6.             I will need special assistance if the hotel is evacuated:             YES o                    NO o

7.             I require the following considerations regarding my health:

                _______________________________________________________________________________

                _______________________________________________________________________________

8.             Any additional requests?

                _______________________________________________________________________________

                _______________________________________________________________________________

PLEASE RETURN COMPLETED FORM BY: September 21, 2007.