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* 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. My reason is: ReasonreasonAre you a manual wheelchair user?*YesNoAre you a powerchair user?*YesNoCan you transfer from your wheelchair to a fixed seat?*YesNoDo you have your own mobility vehicle?*YesNoAre you unable to use public transport for medical reasons?*YesNoDoes your carer have to travel with you?*YesNoDo you have a sight impairment?*YesNoDo you have a hearing impairment?*YesNoDo you use a walking frame?*YesNoDo you use a walking stick?*YesNoOtherOther DisabilityIn emergency please contact:Name*Telephone NoMobile No*Relationship*Address*Doctor NameTelephone NoSurgery NameSCA 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:BritishIrishOther (please state)White Other:Mixed:White & CaribbeanWhite & Black AfricanWhite & AsianOther (please state)Mixed Other:Asian or Asian British:IndianPakistaniBangladeshiOther (please state)Asian or Asian British Other:Black or Black British:CaribbeanAfricanOther (please state)Black or Black British Other:Chinese or other ethnic group:ChineseOther (please state)Chinese or other ethnic group Other:Nationality (please tick one box):Nationality*BritishIrishOther European (please state)Other (please state)Nationality Other:Gender (please tick one box):Gender*FemaleMaleOtherReligion or Belief: Would you like to register a religion or belief?*Yes (if yes please state)NoState Religion:Disability: Do you consider yourself to have a disability?*YesNoIf yes, please tick relevant box below:DisabilityPhysicalLearningSensoryType of Disability:Marital Status: Marital Status*SingleMarriedCivil P’shipDivorcedSeparatedWidowed 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).