Registration Form Please select service required (required) ---Eastleigh Dial-a-RideHedge EndParishlink Title (required) First Name (required) Surname (required) Address (required) Date of Birth (required) Telephone Number (required) Mobile Number (required) Email Address (required) I am unable to use conventional bus services because: (required) I use a walking frameI use crutchesI am visually impairedI use a manual wheelchairI use a walking stickI use a trolleyI live more than 400 yards from a bus stopI use an electric scooter (Please note we cannot carry scooters on the vehicle)I use an electric wheelchair Make and Model of Wheelchair I can transfer from my Wheelchair to a fixed seat YesNo I cannot travel without someone to help me as I need assistance with I would sometimes like to travel with a companion YesNo (Please note that companions must be pre booked and are subject to a standard Dial-A-Ride fare) Are there any medical conditions you feel are relevant? E.g. Heart condition, epilepsy, diabetes, severe medical restrictions etc. Please note: Seatbelts must be worn at all times unless you are medically exempt. If so, please upload a copy of your certificate Please give the name of the person whom we may contact in an emergency: Name: Relationship: (Son, daughter, friend etc.) Daytime Telephone Number: Mobile Number Do you hold any of the following concessionary fare passes? Older person's bus passCompanion bus passDisabled bus passVouchers Please not that: Your details will be held by One Community which complies with the 1998 Data Protection Act and works accordingly to the eight principles of the act. I certify that the information on this form is correct: If your details or circumstances change, please advise us either in writing or by phone. We will contact you periodically to ensure that the details we hold are up to date Eastleigh Dial-A-Ride is operated by One Community and funded jointly by Hampshire County Council & Eastleigh Borough Council. One Community, 16 Romsey Road, Eastleigh, Hants, SO50 9AL. Registered charity no 1052978 Company Ltd by guarantee no 3132524.