Membership Application

Online Membership Application

Title : Other Date of Birth: dd/mm/yy:
   
Foreame(s) : Surname:
Phone No. :
E-mail address :

Address :
Including Postcode

Emergency Contact Details: Name: Phone No:
Doctors
Details:

Doctors Name:

Phone No:

Nature of Mobility Impairment:

Address :

To assist staff plan your journey, please give the following information:

Please select from the list below any of the following mobility aids you needs to use when travelling with Dial-a-Journey
Do you use any other mobility aid not listed or one that requires special transport arrangements such as buggies, scooters or any other specialised equipment. Please give details below
  Can you transfer from your wheelchair to a vehicle seat Yes No
  Access to/from buildings during travel
 

Is there ramped access to your home Yes No
if not state the number of steps

  Do you know of any destinations you are likely to go to that doesn't have ramped access or a maximum of 3 steps

Give Details:

  It is a requirement for all passengers to wear a seat belt unless they have a valid exemption certificate. Can you provide a copy? Yes No
     
 
 


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