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 Bus Pass

Tick if you have a Hampshire Concessionary Pass

Concessionary Pass Type

Older personDisabledDisabled with companion

Hampshire Concessionary Pass Number

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 wheelchairI use an electric wheelchairI use a walking aidI am visually impairedI use an electric scooterI use a shopping trolleyI have a mental health conditionTick if you have difficulty getting on a public bus

Make and Model of wheelchair (if you need to travel in it)

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

Are there any medical conditions which you may think are relevant to making journeys on this service? e.g. Epilepsy, Arthritis, Heart condition, Diabetes etc.

Travel with someone

Tick if you sometimes like to travel with a companion.

If it is essential you travel with someone to assist you, please state why

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

EmailPhasePost

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

We welcome any comment you would like to make about our service