Registration Form - Door 2 Door - Rotherham Community Transport

Title (eg Mr / Mrs / Miss / Ms)

First Name(s)

Surname

Date of Birth

Address

Postcode

Telephone Number

Please tick all of the following boxes which apply to you

Are there any other reasons why you find it difficult or impossible to use public transport for some or all of your journeys?

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

If you use a wheelchair please tick which type you would wish to use when travelling on our services

Powered
Manual

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.

Make

Model

Please note that it will be necessary to disengage the drive clutches on the wheels of your powered wheelchair when boarding and alighting.

If you do use a wheelchair can you transfer to a bus seat?

Yes
No

Do you use a mobility scooter?

Yes
No

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.

Make

Model

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.

If you use a walking aid please tick which type(s):

Walking Stick
Crutches
Zimmer Frame
Other

If other, please specify:

Can you travel in a car?

Yes
No

If YES do you have any special requirements?

Is there anything which will help our drivers find your address?

Will you need any help to get from your door to the vehicle?

Yes
No

Is there anything else we need to know to ensure you are transported safely and comfortably?

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

Name

Relationship (e.g. Son)

Address

Postcode

Phone Number

Monitoring Information

How did you hear about Rotherham Community Transport?

What is your ethnic group?

Any other ethnic group:

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.

How we use your information.

Your personal information will be used by us (including our employees & subcontractors) to assess your eligibility to use our services. If you are not eligible all information will be deleted and the paper registration form will be disposed of. If you are eligible we will enter your data you provide into our scheduling and accounting software to assist us to provide you with the services you ordered and from time to time to communicate with you on any matters relating to the provision of the services we provide. We will not share, sell or distribute any of the information you provide to us unless required to do so by law. There may be times when we need to write to you about the service we provide for you, in this instance, we may share your information with a third party supplier to manage fulfilment on our behalf. Any appointed supplier will be thoroughly screened on their data protection credentials and we will ensure your data is removed as soon as any fulfilment is complete. I consent to RCT holding personal information about me on their computer systems. I understand that this data is used by RCT solely for the purposes related to the provision of transport. I understand that this date will never be shared with any third party except as stated above.

Agree *

I Agree

Name *

Date *