Service Users

Service Users are those unable to access or who are have difficulty accessing local basic services due to lack of transport (eg. access to a car or public transport). They are those who require a transport option to permit them to access basic services.

Service Users include Students, Families, Employed, Unemployed, Retired, Disabled, Community & Voluntary Groups, and many many more…….

Apply For Individual Membership

Apply For Group Membership

This form is available, on request, in a range of alternative formats.

Please contact us if you require any help completing this form on 02870 321234.

If you are not sure if you live within one of the rural community transport operational areas, please telephone 02870 321234.

PERSONAL DETAILS

Please complete in BLOCK CAPITALS and answer all questions. Please tick the appropriate boxes, where indicated to do so.

Title

Your Name *

Your Surname *

Address Line 1 *

Address Line 2

Postcode

Date of Birth *

Telephone Number

Mobile Number *

Your Email Address *

ELIGIBLE MEMBERSHIP CRITERIA

PLEASE ENSURE THAT BOTH OF THE FOLLOWING APPLY TO YOU

This section will confirm if you are eligible to use the Rural Transport Fund Dial-a-Lift services.

ELIGIBLE MEMBERSHIP CRITERIA

I live in a rural area; i.e. an area not covered by the Urban Door to Door Scheme

I have difficulty accessing everyday services due to lack of transport

I do not have access to a car

I do not have access to public transport

If you do have either access to a car or public transport but feel that you may still be eligible for membership please provide supporting information in the box below.

supporting information

Important:

Please note that should the demand for Dial-a-Lift services exceed the amount of resources available, trips will be prioritised on the following basis:

To assist us please tick all statements that apply to you as an individual.

statements that apply to you as an individual

Older person (60+)

Person with a disability

Person with no access to suitable public transport – this is considered as:

being more than 1 mile from nearest bus stop
being on a route that provides less than two return journeys per week between the hours of 10AM to 4PM; or
being on a route that only provides services outside of the hours of 10AM to 4PM

Person with dependants

Person with dependants (dependants include children under 18, older people and dependants with disabilities)

Other

If the services are still over-subscribed then other restrictions may apply.

SMARTPASS INFORMATION

SMARTPASS HOLDER?

SMARTPASS TYPE

SMARTPASS NUMBER

SMARTPASS EXPIRY DATE

NOTE: Please ensure that North Coast Community Transport is advised of any changes to your SmartPass details.

EMERGENCY CONTACT DETAILS

Please provide details of a relative, friend, neighbour, carer or social worker who could be contacted on your behalf in the event of an emergency.

Emergency Contact Name

Relationship to you

Emergency Phone Number

Emergency Mobile Number

TELL US ABOUT YOURSELF

This section is being used so that we can tell our drivers what additional assistance you may require.

PLEASE TICK THE BOXES BELOW WHICH APPLY TO YOU.

I use a wheelchair

My wheelchair is:

Power chair

Manual chair

Chair Make

Chair Model

Other additional assistance

I use a scooter

I use a walking aid

I can transfer from my wheelchair to a seat

I require assistance getting from my front / back door to the vehicle

Please note that our staff will not enter your home / place of residence / destination

I have a medical certificate exempting me from wearing a seatbelt

I enclose a photocopy of my exemption certificate

I am able to travel independently

I require an essential companion(s) to travel with me.

If yes, please state why and how many: (maximum 2

Please note that under 11s are not permitted to travel unaccompanied

I have dependants who may travel with me; i.e. I am personally responsible for the care of a child, older person or a person with a disability.

If you have ticked the above question, please state how many

Other assistance info

I have an assistance dog

I have a learning difficulty

I have a hearing difficulty

I have a visual impairment

I have a speech impediment

Please note that a risk assessment will be carried out by our organisation, as and when required, to ensure that you can travel safely in our vehicles.

EQUALITY INFORMATION

This information is required for equality monitoring and statistical purposes only. As a result we are asking you to answer the following questions. However you do not have to answer them.

Gender

Religion

Martial Status

Ethnicity

Sexual Orientation

Dependants?

(i.e. I have personal responsibility for the care of a child / older person / person with a disability).

DATA PROTECTION STATEMENT

The information that you have given on this form is covered by GDPR. You have the right to see the data that is held about you. The information may be shared with others involved with providing this transport service.

DATA PROTECTION STATEMENT

Yes, I agree to have my information shared

No, I do not want my information shared

Any additional information regarding your travel needs?

Please ensure that you have completed the form and that you have signed and dated it overleaf.

If you are exempt from wearing a seatbelt, please ensure you have enclosed a copy of your exemption certificate.

Please detail below any further relevant information which you feel we may need to know with regards your travel needs:

To assist us with market research, could you please tell us where you learned about North Coast Community Transport:

MEMBERSHIP FEE

Annual membership runs from 1st April until 31st March

£20 per year for individuals who have a Full senior, 60+, Blind Smart Pass or War Disablement SmartPass.

£10 per year for individuals who don’t have a Smart Pass or have a Half-fare Smart Pass

Children under 16 – free membership

Membership Amount:

Membership payment method:

DECLARATION

This is a North Coast Community Transport individual membership application form. A renewal membership form may be required if there has been a gap in my service use or my circumstances have changed. I understand that North Coast Community Transport will contact me from time to time to ensure my membership is still current.

I confirm that the information I have given is correct and that I am responsible for ensuring that North Coast Community Transport is kept informed of any relevant changes in my personal health or circumstances.

I understand that if I do not sign this form and submit the relevant fee then North Coast Community Transport will be unable to process my application.

I understand that by signing this form I agree to abide by the terms and conditions of membership set out by North Coast Community Transport and that all the information provided within this form is true and accurate. I understand that my membership can be refused or revoked if this information is incorrect, if I fail to inform North Coast Community Transport of any relevant changes to my personal health or circumstances or if I fail to comply with the terms and conditions of membership.

Counter Signature

Individuals under 16 must have their application Counter signed below

Counter Signature Title

Counter Signature Name

Counter Signature Surname

Signature

Signature Title

Signature Name

Signature Surname

Thank you for your message. It has been sent.

There was an error trying to send your message. Please try again later.

Group Membership Application Form

Please use BLOCK CAPITALS and answer the following questions
North Coast Community Transport is fully committed to meeting its obligations on the promotion of equality and good relations as set out in Section 75 of the Northern Ireland Act 1998.
For this reason, we need to know certain details about the users of our services.
This information will NOT be used outside North Coast Community Transport to identify you personally.
Statistical type data will be forwarded to the Department for Infrastructure, when requested

ORGANISATION DETAILS:

ADDRESS:

NAME & ADDRESS TO WHICH INVOICES SHOULD BE SENT
(if different from above)

NAME & TEL. No. OF PERSON WE CAN CONTACT IN AN EMERGENCY

ORGANISATIONAL STATUS (Please answer every question):
Profit-making?

A community/voluntary group?

A statutory body?

A registered charity? (Please state No. below)

OUR MINIBUSES MAY ONLY BE USED BY GROUPS INVOLVED IN ONE OR MORE OF THE ACTIVITIES LISTED BELOW.
(Tick those with which your group is concerned)
EducationReligionRecreationSocial welfare

Other activities of benefit to the community? (Please specify below):

AIMS OF YOUR ORGANISATION (Give brief details)

FOR NEW MEMBERS ONLY
What type of transport does your group use at present?

Why is this method of transport no longer appropriate?

PEOPLE WITH WHOM YOUR ORGANISATION IS CONCERNED
(tick as many boxes as are relevant)
People with a physical disabilityPeople with a learning disabilityPeople with mental health difficultiesPeople from ethnic minoritiesPeople with an alcohol related illnessPeople with a drug related illnessPeople affected by HIV or AIDSPeople with dementiaElderly peoplePre-school groupsYouth groupsWomens groupsHealth groups

Other (give details below)

EQUALITY INFORMATION
The Department for Infrastructure is keen to collect information on the members of your group for equality monitoring and statistical purposes. As a result, we are asking you to answer the following questions.
However you do not have to answer them.

THE PEOPLE OF OUR GROUP ARE MAINLY
(Having a DEPENDANT is when you have personal responsibility for the care of a child, elderly person or person with an incapacitating disability)
People with DependentsPeople without DependentsBothNot known

THE PEOPLE OF OUR GROUP ARE MAINLY AGED
Under 1819-65Over 65Diverse Ages

THE PEOPLE OF OUR GROUP ARE MAINLY
MaleFemaleDiverse Gender

THE PEOPLE OF OUR GROUP ARE MAINLY
People With DisabilityPeople Without DisabilityBothNot known

THE PEOPLE OF OUR GROUP ARE MAINLY
ProtestantRoman CatholicBoth Protestant and Roman CatholicOf Other ReligionsDiverseNone of the above

DECLARATION
Our organisation agrees to abide by the terms and conditions as set out in the North Coast Community Transport Minibus Hire Policy, and we understand that any breach of these conditions may result in our group being expelled from membership. We understand that our group is registered under GDPR and we consent to North Coast Community Transport holding the above information about our organisation. We understand that this information will NOT be used outside North Coast Community Transport to identify individual members but that statistical type data may be forwarded to the Department for Infrastructure, for future research purposes

Please submit an annual £25.00 membership fee with your application

SIGNED:

POSITION:

DATE: