Southampton Dial-a-Ride Registration Form If you would like to register to use Southampton Dial-a-Ride, please complete the below form. Title*TitleMr.Ms.Mrs.First Name:* Surname:* Address:* Postcode:* Telephone No: Mobile No:* Email:* Date* 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. My reason is: Reason reasonAre you a manual wheelchair user?* Yes No Are you a powerchair user?* Yes No Can you transfer from your wheelchair to a fixed seat?* Yes No Do you have your own mobility vehicle?* Yes No Are you unable to use public transport for medical reasons?* Yes No Does your carer have to travel with you?* Yes No Do you have a sight impairment?* Yes No Do you have a hearing impairment?* Yes No Do you use a walking frame?* Yes No Do you use a walking stick?* Yes No Other Other DisabilityIn 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: White Other:Mixed: White & Caribbean White & Black African White & Asian Other (please state) Mixed Other: Mixed Other:Asian or Asian British: Indian Pakistani Bangladeshi Other (please state) Asian or Asian British Other: Asian or Asian British Other:Black or Black British: Caribbean African Other (please state) Black or Black British Other: Black or Black British Other:Chinese or other ethnic group: Chinese Other (please state) Chinese or other ethnic group Other: Chinese or other ethnic group Other:Nationality (please tick one box):Nationality* British Irish Other European (please state) Other (please state) Nationality Other: 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: 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* 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).
