BEFORE USING OUR SERVICE

Volunteer Car Service/ Ring & Ride Passenger Registration Detail

Please complete and return to: Stroud District Ring & Ride, Volunteer Car Service & Volunteer Centre, 17 George Street, Stroud, GL5 3DP.  You will be required to pay a £10.00 Annual Registration fee.  You may pay by posting the remiitance to us or  it will be added to your first journey booking

Name: 

Date of Birth:                                                                                Age:

Address:

Postcode:                                                                                   Telephone:

 Emergency contact details

Name & Relationship to you:

Tel No:

Doctors Name, Address & Phone number:

Have you used our service before?                                                                              Yes/No

Will you have anyone escorting you?                                                                          Yes/No

Is there a regular bus service close or near your house?                                      Yes/No

Are you able to travel in a car?                                                                                      Yes/No

Do you need support in and out of the car?                                                                                                                                             Yes/No

Do you need to sit in the front seat of a car?                                                                  Yes/No

Do you need help to carry things i.e. shopping?                                                               Yes/No

Do you use a four wheel walker or any  other walking aid?                                                                         Yes/No

If yes, can it be

folded?                                                                                                                                                                       Yes/No

Will you be paying for this service Yourself                                                                 Yes/No

If other, please explain

Would you mind transferring to the mini-bus service if no car driver is available?                                        Yes/No

Please explain why you would like to use our Service

 

Please tell us how often you will be making this journey and length of stay

Please note that the Volunteer car Service is unable  to provide more than two journeys per week.

 PLEASE NOTE THIS IS NOT A BOOKING FORM PLEASE RING 01453 767771

Pleas submit this form by clicking the link



When completing this form Stroud District Ring & Ride, Volunteer Car Transport and Volunteer Centre will consider this to be your consent to hold this personal information, which is necessary to provide you with our transport services in accordance with the Data Protection Act 1998.  The information is available only to those personnel responsible for administering and providing the transport services at the centre.

Advertisements