Title
Full Name
Address
Postcode
Home Phone
Mobile
Email Address
Gender
Date of Birth
Emergency Contact Name & Relation
Home Phone
Mobile
2nd Emergency Contact Name & Relation
Home Phone
Mobile
Other (please specify below)
Where did you hear about us?
What is the main reason for using the service? eg. medical appointements, leisure, shopping
Additional information If you are willing, we would be grateful if you could provide us with additional information. This can help us with grant funding, enable us to provide services to those who need it most & establish equality for all. This section is not mandatory but very helpful.
Please tick the appropriate boxes.
Housing Home Owner Council Rented Private Rented Homeless Assisted Living / Care Home Other Other (please specify below)
Employment Employed Full Time Employed Part Time Retired Unpaid / Voluntary Unemployed Unable To Work Student Full-Time Parent Other (please specify below)
Ethnicity White British White Irish White Gypsy / Irish Traveller Any Other White Background White & Black African White & Black Caribbean African Caribbean Any Other Black Background White & Asian Arab Bangladeshi Chinese Indian Pakistani Any Other Asian Background Any Other Mixed Background Any Other Ethnic Group Other (please specify below)
Any Other Information We Should Know? Eg. Medical issues, Access To Property Instructions, Additional Travel Requirements
Wheelchair Users
Can you transfer?
If yes, please note the Make & Model below
PLEASE NOTE If you use an electric scooter you will need to be able to transfer to a bus seat once you have boarded the vehicle. The scooter can be transported with you to your destination.
If you use a wheelchair, it is possible for you to remain in the chair if you are unable to transfer to a seat however the wheelchair must have been Crash Tested by the manufacturer.
Journey payment: Cash on the day of travel
However, if you wish to be invoiced call 01444 471919 or fill in the details below:
Name of payee
Email
Contact Number
In this pack, you are being asked to submit personal information about yourself (e.g. name and e-mail address) in order to receive or use our services. These include all the services available to members of CT Sussex (Bluebird Community Transport). By entering your details in the fields requested; you enable CT Sussex to provide you with the services available to members. Any personal information you provide to us will only be used by us, our agents, and service providers, and will not be disclosed unless we are obliged or permitted by law to do so. If not signed by the passenger, please note name & relation
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