Avelo Customer Wheelchair Information

If you plan on traveling with your wheelchair, please complete this form and attach it to your wheelchair. You may type in your responses in the fields below, click the checkboxes, and print out the completed form; or print out a blank form and complete it by hand.

Name of traveler (required):
Chair serial number:
Chair type:
Power Manual
Battery type (required):
Gel/dry (non-spillable) Acid/wet cell (spillable) Lithium
Chair weight (required):
lbs.
Is it key operated?
Yes No
How are the brakes or wheel locks released?
Which parts fold or collapse (if applicable)?
Are there any removable parts (e.g., foot rests, seat cushions, etc.)?
Yes No
Will you bring any parts of the chair into the aircraft cabin?
Yes (list below) No
Are any tools required?
Yes (list and briefly describe function) No
Special instructions or precautions, including how to deactivate/reactivate the battery:

Avelo Customer Wheelchair Information Form

Avelo Customer Wheelchair Information

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