Registration Form

Name:

Address:

Telephone Number:

Date Of Birth: DD/MM/YYYY

Gender:

Ethnicity:

Nature Of Disability:

Wheelchair User:

Type Of Wheelchair:

Transfer To A Seat:

Emergency Contact Name:

Emergency Contact Number:

Data Protection Assurance. Completion of this form is for the sole purpose of recording your details on the Gloucester Dial-A-Ride Register. All data processed by Gloucester Dial-A-Ride is in accordance with the provisions of the Data Protection Act 1998. Your details will only be used for administration purposes by Gloucester Dial-A-Ride staff or agents and will not be released to any third party without your written consent.