Register Form

£10.00 Online Registration Fee

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.

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

Addition Information

Please tick any box that apply to you.

Folding Zimmer Frame: Yes
Non-Folding Zimmer Frame: Yes
Manual Wheelchair: Yes
Folding Wheelchair: Yes
Electric Wheelchair: Yes
Essential Escort: Yes
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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 you are giving you consent.
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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
No

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How did you hear about our community transport service

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