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COMMUNITY ACTION PARTNERSHIP

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REGISTER WITH US

Community Transport Registration Form

Title

Mrs

Miss

Full Name*

Address*

Postcode*

Telephone Number

Mobile Number*

Date of Birth*

Email*

Do you use any walking aids? Walker, sticks etc.*

Yes

If yes, please give details

Do you use a wheelchair?*

Yes

If yes, please give details - we may need to come and risk assess before you take any journeys

Do you drive or have access to a car?*

Yes

Are you able to use public transport?*

Yes

Reason(s) you have difficulty using public transport (please tick appropriate boxes)*

Walking difficulties

Wheelchair user

Sensory difficulties

Physical difficulties

Learning difficulties

Mental health

Physical health

Frail elderly

Illness

Please provide as much supplementary information as possible re your health and walking needs, i.e unsteady on feet, please come to the door to get me, etc.

Where did you hear about our Community Transport service?*

Please provide the name and contact details of somebody we can contact in case of an emergency:

Name*

Telephone Number*

Relationship to your emergency contact*

The information provided is given to the best of my knowledge. I consent to Community Action Partnership storing this information whilst I am using the service and can withdraw my consent at any time. I understand that I must inform Community Action Partnership of any change in my circumstances in relation to, but not exclusively, my health, mobility, contact details etc.

Name*

Signed*

Date*

Data Protection Act 1998 & GDPR 2018

The information you provide on this form will be entered onto a database and used solely for the delivery of Community Transport services.

Please don’t forget to pay your £5 registration fee – thank you.

Once you are registered on the scheme, we will call you to confirm we are ready to take your bookings.

Do you have a working smoke alarm at your property?*

Yes

COMMUNITY ACTION PARTNERSHIP

Main Office

Office 5 & 6 Northfield Lodge

35 Leicester Road

Blaby

LE8 4GR

Website

Registered charity number 1118572

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