NDDCT Membership form

Membership Registration Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Postal CodeCountry
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Details
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Post codeCountry
Phone Number
Please enter a valid phone number.
Email
example@example.com
Do you use a Carelink Service?

YESNO
If so which service?
Are you happy for us to contact them if we are concerned about your welfare (i.e. if you didn’t answer the door when we are due to collect you, or if you were taken ill whilst using community transport)?

YESNO
Accessibility
Is there easy parkingoutside your home?

YESNO
If your home is not easy to find please provide directions:
Do you need any assistance from your home to our transport?

YESNO
If you use a wheelchair,are you able to transfer to a vehicle seat if needed?

YESNO
Do you use (select all that apply)

WalkerShopperOxygen Cylinder
Do you have any allergies?
Where did you hear about us?
Please indicate which services you would like to use:

SHOPPINGDIAL-A-RIDETRIPS
Declaration:
I wish to apply to become a member of Nailsea & District Community Transport and agree to abide by its conditions of registration and carriage. I confirm that NDCT may use and/or share the above information in regards to transport issues and if they have concerns for my welfare only, and that I may revoke this authority at any time in the future.

Please contact us on 01275 855552 to pay by card we will never ask for payment online.
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Membership Registration Form

Emergency Contact Details

Accessibility

Declaration: