Wheelchair/Scooter Information Form - Southwest Airlines

1 Wheelchair/Scooter Information Form Please take the time to fill out this form before arriving at the airport, and provide as much Information as possible. Either present a copy of this form when checking your assistive device or attach a copy to your device so that we can assist you in the manner you require. Thank you, and have a wonderful flight! Customer Name Confirmation Number Phone Number Alternate Phone Number Destination Power Wheelchair/Scooter Check Battery Type Wet Cell Battery/Spillable (SWA to remove from device) Dry Cell Battery/Nonspillable (Battery will remain installed) Lithium-ion (Li-ion) Battery (Battery will remain installed) Lithium-ion (Li-ion) Battery (Battery will be removed and transported in cabin) Manual Wheelchair/Other Manual Devices Check Applicable Box Foldable/Collapsible Not Foldable/Collapsible Indicate recommendations for where and how to lift.

2 (Y ou may attach a picture of your own wheelchair.) Removable Parts Stay with Wheelchair/ scooter Stow in Cabin Head Rest Leg Rest(s) Seat Cushion Control Stick Arm Rest(s) Side Protectors Chair Back Tray Belts/Straps Wheels Other (please note): Rev. 5/2015