Personal Details

First name

Last name

Date of Birth

Address

Please give directions to your property if you feel we may find it difficult to locate you or any access problems

Mobile Number

Phone Number

Email

Emergency contact name, number and relationship to you

Health

Name & address of doctor

Do you suffer from any health related problems that we should be aware of when travelling with ACT? For example, Epilepsy, Diabetes, Allergies, bladder weakness, Alzheimer’s, Dementia

Are you registered blind or partially sighted?

Yes

No

Mobility

Do you have any Mobility aids? (Wheelchair, transferable wheelchair, walking frame, stick, crutches, electric scooter or shopping trolley)

Yes

No

Gold Card Details

Gold Card Number

Expiry Date

Please note that passengers without a valid Gold Card are unable to travel on the shopping buses at the subsidised rate. However, Gold Cards are available at the council offices at Ashbourne Leisure Centre.

Declaration

Declaration that I am unable to use public transport or it is not available in my area

Please select one or more of the options below to help us understand your individual needs;

ASHBOURNE COMMUNITY TRANSPORT

Passenger Registration Form

Personal Details

Health

Mobility

Gold Card Details

Declaration