Passenger Registration Form - Norwich Door to Door

Title *

Name *

First

Last

Do you live and travel within the Southern Bypass and the Broadland Northway?

Yes – please complete the details below
No – please call 01603 776735

Address *

Postcode *

Email *

Phone *

Mobile Phone

Day of birth *

Month of birth *

Year of birth *

Wheelchair User (if yes give details in next fields) *

Wheelchair Manufacturer and Model

All scooters and wheelchairs must have a crash test certificate

Wheelchair Serial Number and Weight

Maximum weight permitted 120kg – check plate on back

Wheelchair

Electric
Manual

Electric wheelchairs will be disengaged to access bus lift and positioned on lift by driver/passenger assistant

Nature of Your Disability *

Including allergies/asthma/epilepsy/medication carried

Your Travel Needs/Equipment/Medication/Escort *

Oxygen flasks are not acceptable unless they are attached to the wheelchair of the passenger in a purpose built safe and stable sturdy wire carrier

Access to your Home *

Describe any obstructions/hazards for parking or passenger access/exit from property to bus

Do you have a Blue Badge? *

Emergency Contact Name *

First

Last

Emergency Contact Relationship *

Emergency Contact Number *

How do you currently travel?

Tick all that apply

Other Form of Transport

For what reason do you wish to use our service?

Tick all that apply

How do you feel about your current transport situation?

I feel isolated *

1 = strongly disagree and 10 = strongly agree

I feel confident *

1 = strongly disagree and 10 = strongly agree

I see friends and family regularly *

1 = strongly disagree and 10 = strongly agree

I am actively involved in my community *

1 = strongly disagree and 10 = strongly agree

How did you hear about Norwich Door to Door? *

Other

Do you wish to receive newsletters and fundraising information? *

Yes
No

Gift aid *

I am not a UK taxpayer
I agree that gift aid can be claimed on my donations

I would like to Gift Aid all donations I make to Norwich Door to Door. I am a UK taxpayer and understand that if I pay less Income Tax or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in a tax year it is my responsibility to pay any difference.

I will notify Norwich Door to Door if I wish to cancel this declaration, change my name and home address, no longer pay sufficient tax on my income and/or capital gains.

Photo & video *

I agree that you can use photographs and video footage which feature me to promote Norwich Door to Door
I do not give permission for you to use photographs of me

Consent *

I agree to the privacy policy

I apply to register with Norwich Door to Door and agree to abide with its conditions of registration and carriage.

I agree to my details being kept on record by Norwich Door to Door and all information I give will remain confidential in accordance with the Data Protection Act 1994. A copy of Norwich Door to Door’s conditions of carriage and registration is available in multiple formats on request.

Please note Door to Door service reserves the right to refuse or defer an application for registration, to ask for additional information in support of an application, or cancel any existing registration at the at the discretion of Norwich Door to Door.

I would like to become a passenger of Norwich Door to Door