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Registration
To register to use our services please complete the form provided below.
Surname
Forename(s)
Title
Select a Title
Mr
Mrs
Miss
Mz
Dr
Date of Birth
Address
Post Code
Telephone
Is there anything that will help our drivers to find your address?
Please tick each of the boxes which apply to you.
I need to use a walking aid
If you use a walking aid, please select
Select a Walking Aid
Walking Stick
Crutches
Zimmer Frame
I need to use a wheelchair
If you use a wheelchair please select
Select a Wheelchair
Manual
Electric
I find it difficult to climb stairs
I find walking difficult
I find it difficult to stand for any period
I have a learning difficulty
I am registered as blind or partially sighted
I have a hearing difficulty
I receive Disability Living Allowance
I have a speech difficulty
I receive a War Pensioners Mobility Supplement
I receive attendance allowance
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 in an emergency.
Name
Relationship to you
Address
Post Code
Telephone
Declaration
By submitting this form you confirm that:
The above details are correct in support of your registration, and that you find it difficulty or impossible to use public transport.
You understand that Rotherham Community Transport reserves the right, in exceptional circumstances, to seek independent medical advice to confirm your eligibility.
You will inform Rotherham Community Transport of any changes in your circumstances that may affect your eligibility to use these services.
You consent to the information that Rotherham Community Transport holds about you being made available to the South Rotherham Passenger Transport Executive, as funder of these services, and its authorised agents.
If you agree with this declaration then please tick the box provided below.
Agree Yes/No
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Use our on-line Booking Service by clicking Book Now or ring 01709 517100.
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