To register for our community transport service please complete the form and pay your registration fee. To book to use Community Connexions bus services please call 0345 6805029. All bus routes are chargeable public bus routes, bus passes are accepted.

Registration Form

Personal Details

We require this information in order to provide our services to you. It is held on a secure UK database and is not shared with any 3rd parties.

Title

Forename

Surname

Address Line One

Address Line Two

City

Postcode

Primary Telephone Number

Secondary Telephone Number

Date of birth

Email Address

Next of Kin or person to be contacted in an emergency

We make the assumption that you have the permission of this person to give us their details.

Title

Forename

Surname

Address Line One

Address Line Two

City

Postcode

Primary Telephone Number

Secondary Telephone Number

Email Address

Additional Information

Please tick any box that applied to you.

Folding Zimmer Frame

Non-Folding Zimmer Frame

Folding Wheelchair

Travels in a Wheelchair

Electric Wheelchair

Essential Escort

I hereby give my consent to Community Connexions retaining information on my health or any other sensitive data relevant to me using their service and to disclosing my personal details in the event of an extreme emergency.

By ticking here, Yes I am giving you consent (required).

Are you happy for us to inform you of future offers of similar services, to send you newsletters and obtain service feedback? This information is not shared with any third party and you can unsubscribe at any time (required).

Yes

How did you hear about our community transport service?

On clicking “Submit Form” below your information will be sent to Community Connexions for processing.

Online Registration

To register for our community transport service please complete the form and pay your registration fee. To book to use Community Connexions bus services please call 0345 6805029. All bus routes are chargeable public bus routes, bus passes are accepted.

Registration Form

Personal Details

Next of Kin or person to be contacted in an emergency

Additional Information