Individual Membership Application Form

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Schott House, Drummond Road, Stafford, ST16 3EL
0800 043 6672
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Home
About Us
Booking
Passengers
- Become a Member
- Groups and Organisations
Support Us
- Volunteer
- Donate
News & Vacancies
Contact Us

Step 1 of 4

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We need a few personal details for your membership.
Title*
Name*
First Last
Date of Birth*
Address*
Street Address Address Line 2 City County Postcode
Phone number*
Email address
Are you registered disabled?*
Do you have a Blue Badge?*
If Yes, who issues your Blue Badge?

We need a few details to check that you are eligible to use our community transport service.
Do you have a physical disability?*
- Yes
- No
Do you have a learning disability?*
- Yes
- No
Do you have a hearing impairment?*
- Yes
- No
Do you have a sight impairment?*
- Yes
- No
Are you temporarily disabled through illness or accident? if yes please give details below.
Do you have difficulty getting on an ordinary bus?*
- Yes
- No
Are you unwaged?*
- Yes
- No
Are you pregnant?*
- Yes
- No
Do you own a car?*
- Yes
- No

MOBILITY - A few questions about you mobility.
Do you require assistance to get around?*
- Yes
- No
For example, someone to guide you or support you.
Do you require someone to travel with you?*
- Yes
- No
For example, a family member, carer or friend.
Do you use a wheelchair?*
- yes
- No
If yes, is you wheelchair
- Manual
- Electric
Do you use a walking aid?*
- Yes
- No
If yes, is your walking aid a
- Stick
- Tripod
- Frame

EMERGENCY CONTACT - Should an emergency arise we need to know who you would like us to contact. (you should have the consent of this person to disclose their details)
Name*
First Last
Phone Number*
Relationship to you.*
I hearby authorise Communit Link to keep these details on their database until such time as my membership lapses.*
- I agree
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