Become a Member

Membership Form

About you

Title

MrMrsMsMissOther

Full name

Address

Postcode

Telephone

Date of birth

Please give some details of someone we can contact in an emergency

Name & address

Telephone

Relationship to you

Please select the services you require

Dial-a-Journey Transport ServicesCentral ShopmobilityBoth

Please complete the following information to help us ensure a safe and comfortable experience

What is the nature of your impairment?

Is this impairment:

TemporaryPermanent

For Dial-a-Journey customers

Applicants must be unable to use conventional bus services due to a significant mobility impairment.

Services you wish to use (tick both if applicable):

Local authority, door-to-door transport servicesOther transport services provided by DAJ

Are you likely to use any of the following mobility aids?

Manual WheelchairElectric WheelchairWalking FrameGuide Dog

Do you have ramped access to your home?

YesNo

If not, please let us know how many steps from your home to ground level (max 3)

0 Steps1 Step2 Steps3 Steps

Are you able to travel without assistance?

YesNo

If you hold a national concession scheme card - are you eligible to be accompanied by an assistant (Does your card have C+1 on the front)?

YesNoN/A

For Central Shopmobility customers

Approximate Weight
(It is necessary to ask this question in order that our staff can give you a chair that suits needs. Please tick):

Under 15 stone15 - 18 stone18 - 22 stoneOver 22 stone

What type of equipment do you usually use?

Manual4 Wheel Power Chair3 Wheel Scooter4 Wheel Scooter

Are you trained in the operation of the following?

Manual4 Wheel Power Chair3 Wheel Scooter4 Wheel Scooter

Declaration

Data Protection Act 1998 Order of Malta Dial-a-Journey Ltd are registered as Data Controller with the Information Commissioner Office, for the purpose of compliance with the legal requirement of the Data Protection Act 1998. What we do with this information Order of Malta Dial-a-Journey use the information providied in this application form for the purposes of delivering Dial-a-Journey and local authority funded services. Information may be shared with the local authority in whose area you reside for the purposes of research, planning, delivering and monitoring these services. This information will not be shared/sold to any other party.

I confirm that: I do not have any condition that impairs my ability to safely operate powered equipment (such as 3 or 4 wheeled scooter or power chair), lent or hired to me I promise to immediately inform Central Shopmobility if I become aware of any change in my condition that impairs my ability to safely operate powered equipment I agree to undertake an assessment or re-assessment of my ability to safely operate powered equipment when requested by a member of Central Shopmobility staff I undertake full responsibility for the equipment whilst in my care and in particular will ensure that: 1. The equipment will be used with care and consideration 2. The registered user will be the only user of the equipment 3. The equipment will be returned to the Shopmobility Office 15 minutes prior to close of business I have been given a copy of "Get Wise" the BHTA Highway code for electric scooter and wheelchair users I will inform Central Shopmobility immediately of any accidents or incidents when I am in possession of the equipment I will inform Central Shopmobility of any defect or damage to the equipment arising when I am in possession of the equipment. I accept that where damage to equipment can be attributed to misuse/abuse, the cost of repair may be recovered from myself I agree to abide by the rules of the scheme as published and will not allow any other person to use my membership I understand that membership is renewable annually and may require completion of revised membership forms.

Please tick here to confirm that you agree with the declaration and statements above.
Yes