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Registration

To register to use our services please complete the form provided below.
Surname  
Forename(s)  
Title  
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  
I need to use a wheelchair  
If you use a wheelchair please select  
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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