Registration Form

Please fill in the form below to register to use Rotherham Community Transport services,
or click here to download a PDF version for you to fill in and send back to us.

Please tick all of the following boxes which apply to you.

I need to use a walking aid, e.g walking stick I find it difficult to climb steps I find it difficult to stand for any period I have a learning disability I am registered as partially sighted or blind I have a guide/assistance dog I receive disability allowance I use a wheelchair I find walking difficult I have a hearing impairment I receive attendance allowance I receive a war pensioner's mobility supplement

To help us provide you with the most appropriate service please provide the following information:

If you use a powered wheelchair, please provide details of the make and model. We need to ensure that your wheelchair can be transported safely.

Please not that it will be neccessary to disengage the drive clutched on the wheels of your powered wheelchair when boarding and alighting.

Class 2 scooters, no more than 600mm wide and 1000mm long, weighing up to 65kg can be used on Community Transport vehicles. Unfortunately we are not able to accommodate Class 3 scooters which are designed for use on the road.

If you use a scooter please provide details of the make and model. We need to ensure that your scooter can be transported safely.

Please note that for safety reasons it is not possible for you to remain on your scooter on the passenger lift or inside of the vehicle. For this reason you will need to be able to use the passenger lift or the side entrance.

Please give details of someone we can contact on your behalf should the need arise

How did you hear about Rotherham Community Transport.

Doctor Occupational Therapist Door 2 Door Leaflet I've seen your busses Connect to Support Rotherham Hospital Social Services Word of Mouth Social Prescribing Project

What is your ethnic group?

White British Other White Background Indian Chinese Other Asian Background Caribbean White & Asian Dual Heritage White & Black Caribbean White Irish Bangladeshi Pakistani Other Chinese Background African Other Black Background White & African Dual Heritage Other Dual Background

Declaration

In submitting this application I confirm that:

All the information I have supplied is accurate I find it difficult or impossible to use public transport I understand that Rotherham Community Transport reserves the right to seek independent medical advice to confirm that I am eligible to receive support I accept the conditions of carriage relating to mobility scooters and electric wheelchairs I will inform Rotherham Community Transport of any changes in my circumstances which may affect my eligibility to use the community transport services I accept that, when deemed necessary, a risk assessment relating to my safety when travelling will be carried out