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REGISTER WITH US

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Community Transport Registration Form

Title
Mr
Mrs
Miss
Ms
Do you use any walking aids? Walker, sticks etc.
Yes
No
Do you use a wheelchair?
Yes
No
Do you drive or have access to a car?
Yes
No
Are you able to use public transport?
Yes
No
Reason(s) you have difficulty using public transport (please tick appropriate boxes)

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.

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

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.

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
No

Main Office

Office 5 & 6 Northfield Lodge

35 Leicester Road

​Blaby

LE8 4GR

Website

Registered charity number 1118572

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© 2023 by Community Action Partnership. All rights reserved.

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