Southampton Dial-a-Ride

• Title*
  TitleMr.Ms.Mrs.
• First Name:*
• Surname:*
• Address:*
• Postcode:*
• Telephone No:
• Mobile No:*
• Email:*
• Date*
  Date Format: DD slash MM slash YYYY

The Dial-a-Ride service is specifically designed for use by people who are unable to use existing public transport. Please confirm below your reasons for being unable to use public transport.

In emergency please contact:

• Name*
• Telephone No
• Mobile No*
• Relationship*
• Address*
• Doctor Name
• Telephone No
• Surgery Name

SCA Transport is committed to ensuring equal opportunities for all prospective employees, current employees, volunteers, self employed contractors and customers. To ensure that we achieve this and do not discriminate, please give details of the following. All questions are optional; if you do not wish to give a particular piece of information please leave blank:

• Ethnic Background (please tick one box):

• White:
  • British
  • Irish
  • Other (please state)
• White Other:
• Mixed:
  • White & Caribbean
  • White & Black African
  • White & Asian
  • Other (please state)
• Mixed Other:
• Asian or Asian British:
  • Indian
  • Pakistani
  • Bangladeshi
  • Other (please state)
• Asian or Asian British Other:
• Black or Black British:
  • Caribbean
  • African
  • Other (please state)
• Black or Black British Other:
• Chinese or other ethnic group:
  • Chinese
  • Other (please state)
• Chinese or other ethnic group Other:

• Nationality (please tick one box):

• Nationality*
  • British
  • Irish
  • Other European (please state)
  • Other (please state)
• Nationality Other:

• Gender (please tick one box):

• Gender*
  • Female
  • Male
  • Other

• Religion or Belief:

• Would you like to register a religion or belief?*
  • Yes (if yes please state)
  • No
• State Religion:

• Disability:

• Do you consider yourself to have a disability?*
  • Yes
  • No

• If yes, please tick relevant box below:

• Disability
  • Physical
  • Learning
  • Sensory
  Type of Disability:

• Marital Status:

• Marital Status*
  • Single
  • Married
  • Civil P’ship
  • Divorced
  • Separated
  • Widowed

I give my consent that any information given may be stored as computerised or manual data. This data may be used for the purposes of monitoring the makeup of our customer base and may be seen by senior managers or officers of the company involved in the monitoring of such data.

• Name*
• Date*
  Date Format: DD slash MM slash YYYY
• *
  • I consent to my data being collected and stored as stated in the Privacy Policy.

• By completing this form you confirm that you are not able to use existing public transport due to a disability (please note that in some circumstances we may request a signed letter from your doctor to confirm your eligibility for the Dial a Ride service).