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

Tick if you have a Hampshire Concessionary Pass

Concessionary Pass Type

Older person
Disabled
Disabled with companion

Please put Hampshire Concessionary Pass Number in box below

Pass expiry Date

By ticking this I accept I have a mobility or sensory impairment that causes me discomfort in using a public bus.

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.)

I use a manual wheelchair
I use an electric wheelchair
I use a walking aid
I am visually impaired
I use an electric scooter
I use a shopping trolley
I have a mental health condition
Tick if you have difficulty getting on a public bus
Disabled with companion
Tick if you travel with a wheelchair & can transfer to a seat?"
Tick here to say your wheelchair collapsible

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

Tick if you sometimes like to travel with a companion.

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
EmailPhonePost

If you already use the Dial-A-Ride, could you please let us know how satisfied you are with the service?Very SatisfiedSatisfiedNot Satisfied