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INDIVIDUAL MEMBERSHIP APPLICATION FORM

Please give your personal details.

Your Family Name

Title: Please underline as appropriate.
Mr. Mrs. Miss. Ms. Dr. Rev. Other (please specify):

Your First Name

Your Date of Birth

Your Address

Your Post Code

Your Telephone Number

Your e-mail address (if any)

Your Cambridge City Bus Pass (if any)

Bus Pass Number

Current Pass Expiry Date

Please indicate any condition (other than age) which makes mobility difficult for you.

Please indicate any of the following which will apply when using the services of Cambridge Dial-a-Ride:

	Please underline as appropriate.
I use a manual wheelchair.	I use an electric wheelchair.
I use a manual wheelchair but will transfer to a seat when travelling with Dial-a-Ride.	I use a walking frame or similar aid.
I will travel with an escort to assist me.	I will travel with my guide dog.
I will wish to use the Shopmobility service in the Grafton Centre and/or Cambridge city centre.

Please identify a contact in case of any emergency while you are using Cambridge Dial-a-Ride services.

Name	Telephone
Relationship to you

Please indicate how you heard about Cambridge Dial-a-Ride: ..................................................................................

I wish to apply for membership of Cambridge Dial-a-Ride. I have read the Cambridge Dial-a-Ride information brochure or web-site and agree to use the procedures and services as laid out there. I enclose the £10 annual membership fee as a cheque or Postal Order made payable to “Cambridge Dial-a-Ride”.

Signed by or on behalf of the applicant:

Date:

Please send the completed application form by post to:
Cambridge Dial-a-Ride, Unit B, Rene Court,1 Coldhams Road, Cambridge. CB1 3EW
camdar05@hotmail.co.uk

Company Limited by Guanantee: Registered Number 3172130 Registered Charity: Number 1053924