EASTLEIGH DIAL-A-RIDE & HEDGE END PARK SERVICE

Eastleigh Community Services

E.C.S. House

16 Romsey Road

Eastleigh. SO50 9AL

Tel: (02380) 902450 & (02380) 902432

 

APPLICATION FORM

Dial-A-Ride is a door-to-door transport service for people who due to their disability are unable to use public transport.

If you feel that you are eligible for this service and would like to use it, please complete this form and return it to the above address.

 

NAME: -

 

DATE OF BIRTH: -       

 

ADDRESS: -

 

                                  

 

 

POST CODE: -                                            TEL.NO: -

 

 

Please state what disability prevents you from using public transport?

 

 

 

 

 

 

Do you use either of the following?  (Please tick)

 

Wheelchair                           Walking frame                    Sticks/Crutches 

 

Do you receive a Mobility Allowance?                           Yes       No

 

Are you registered disabled with Social Services?    Yes       No

 

 

If you wish for an essential escort to travel with you, please

explain why this is necessary:-

 

 

 

 

 

Please give the name and address of the person who should be contacted in case of an emergency: -

 

  Name: -

 

  Address: -

 

 

 

 Tel. No: -

 

I hereby declare that due to my disability, I am unable to use public transport

I consent to my details being entered on computer.

 

Signed: _____________________________ Date:            /           /

 

  IMPORTANT NOTES

 

The information that you have provided on this application form is of a personal and confidential nature. There may be occasions when this information (in particular your medical condition), would be helpful to the driver, in order for us to ensure a safe and comfortable journey.  If you have no objections to the information on this form being disclosed for this reason, then please do not contact us. If you do not want the details on this form used in this way, then please make a note of it on this application form.

 

These details will be placed on computer and under the Data Protection Act; we are required to ask if you object to this.

 

 

 

A PROJECT OF EASTLEIGH COMMUNITY SERVICES