• Transport Membership Application Form

    Transport Membership Application Form

    This form is available in a range of alternative formats. If you are not sure if you live within one of the Disability Action Transport Scheme areas, please contact us on 028 9029 7870.

  • Section 1: Personal Details

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  • Section 2: Emergency Contact Details

    This section is optional but it would help us if you nominated a relative, friend or neighbour who maybe be contacted on your behalf in case of an emergency.

  • Section 3: Tell us about yourself

    The next section is being used so that we can tell the driver of the Disability Action Transport Scheme what additional assistance you may require. Please tick the boxes below which apply to you (otherwise leave blank).
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  • Please note:

    A risk assessment may be carried out by our organisation, as and when required, to ensure that you can travel safely in our vehicles

    Under 11's are not permitted to travel unaccompanied

    Not all scooters can be accommodated on board our vehicles

  • Section 4: Eligible Membership Criteria

    This section is to confirm that you are eligible to use the Disability Action Transport Scheme. Please tick one of the following boxes:
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  • EQUALITY INFORMATION

    This information is required for equality monitoring and statistical purposes only. As a result we are asking you to answer the following questions. However, you do not have to answer them.

  • DATA PROTECTION

    By submitting your application, you are providing consent for us to share and process your personal information as detailed below.We will use the personal information we collect about you to:

    •Consider your application/membership for community transport services. This includes sharing your infomration between Disability Action and Down Armagh Rural Transport Partnership for the purpose of providing you with transport services.

    • Provide you with community transport services if your application is successful.

    • Comply with legal or regulatory requirements.

    It is in our legitimate interests to decide whether we can provide community transport services to you and, if your application is successful, to provide those services to you, as it would be beneficial for our business to do so.

    We also need to process your personal information to decide whether to enter into a contract for the provision of community transport services with you.

    Having received your application form, we will process that information to decide whether you qualify to receive our community transport services.

    If we do agree to provide you with community transport services, then we will use the personal information to provide you with those services.

    Unless you request us not to do so, we will share the information in the section headed “Equality Information” with the Government department that provides our funding.

    This information will be shared for equal opportunity and/or diversity monitoring and reporting and will only include the information set out in that section.

    Our Privacy Policy can be found here.

  • DECLARATION

    This is a Disability Action Transport membership form in partnership with Down Armagh Rural Transport (DART) Partnership.

    I confirm that the information I have given is correct and that I am responsible for ensuring that Disability Action and DART are kept informed of any relevant changes in my personal health or circumstances.

    I understand that if I do not sign this form and upload the relevant documentation that my application will not be processed.

    I understand that by signing this form, I agree to abide by the terms and conditions of the membership set out by Disability Action and that all the information provided within this form is true and accurate.

    I understand that my membership can be refused or revoked if this information is incorrect, if I fail to inform Disability Action of any relevant changes to my personal health/circumstances or if I fail to comply with the terms and conditions of the membership

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  • Under 16's applications must be countersigned by a parent/guardian.

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  • If you are signing on behalf of the applicant, please print your name and relationship to them eg: friend/relative

    Name:      
    Relationship:      

  • A copy of our membership terms and conditions will be sent out to you once your membership has been processed.

  • If you require any additional information, please contact us on the details below.

     

    Disability Action Transport Scheme

    Portside Business Park,

    189 Airport Road West, Belfast

    BT3 9ED. 

     

    Telephone: 028 9029 7870

    Email: transport@disabilityaction.org

    Web: www.disabilityaction.org/transport

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  • Please now SUBMIT your form

     

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