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Dial-a-ride form

new DAR form

    Dial-a-Ride Registration Form
    Who is eligible to register for the Dial-a-Ride service?

    The service is available to anyone who has a mobility or sensory impairment which means that they are unable to or experience difficulty or discomfort in using bus services.

    If you meet the eligibility requirement, and would like to register, please complete this form.

    Name

    Address

    Postcode

    Telephone Number

    Email Address

    Concessionary Pass Type



    Please put Hampshire Concessionary Pass Number in box below

    Pass expiry Date

    Please note that by law only wheelchairs certified as safe to travel can be transported. Please call us for more information and to check your wheelchair. Tel: 023 8090 2450 This DOES NOT apply to manual chairs where users can transfer to a seat- it is always safer to transfer to a fixed seat for travelling.

    Which of the following apply (you may tick more than one.)










    ?"

    Please note that seatbelts must be worn at all times unless you are medically exempt. If so, PLEASE send us a copy of the certificate.

    Medical Conditions

    Travel with someone

    Please give details below of whom we may contact in an emergency

    Name

    Address

    Relationship to Passenger

    Evening Telephone Number

    Mobile Telephone Number

    Privacy Notice

    Eastleigh Dial-A-Ride is a service operated by One Community

    From time to time we would like to contact you with details of events, trips and services you may be interested in.
    If you consent to us contacting you for this purpose please tick to say how you would like us to contact you

    All our data is collected and stored in compliance with GDPR and our privacy statement. If you have any questions about how we store and use your information please contact us by ringing 023 8090 2400 or emailing info@1community.org.uk .

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      023 8090 2400

      info@onecommunity.org.uk

      Our office


      75 Leigh Road
      Eastleigh
      Hampshire
      SO50 9QD

      Contact Us

      023 8090 2400 info@1community.org.uk

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        Fax 023 8090 2413
        Textphone 023 8090 2400
        Registered Office 75 Leigh Road, Eastleigh, Hampshire, SO50 9DQ. Registered Charity Number 1052978. Registered in England as a company limited by guarantee. Company Number 3132524.