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.
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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.
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.
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.
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 (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.
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
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:
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:
Marital 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.
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
£10 per year for individuals who have a Full senior, 60+, Blind Smart Pass or War Disablement SmartPass.
£5 per year for individuals who don’t have a Smart Pass or have a Half-fare Smart Pass
Children under 16 – free membership
Membership:
Cash Cheque Bacs (sort code 938627 account 02453219)
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.
CounterSignature
- Individuals under 16 must have their application Counter signed below
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Signature
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