Title	Name				Date of Birth
Address
						Post Code
Telephone			Mobile Tel			E-mail:
Emergency Contact					Relationship
Address
					Telephone No.
Long term illness or disability
Do you take any medication?			Yes/no	If yes please provide details:
Do you use any of the following aids (please ring)
Walking Stick		Frame		Wheelchair			Power wheelchair
Make and model of wheelchair if known
Scooters cannot be accommodated on our vehicles without special arrangements
Do you use
A) Breathing aids ?		Yes/no		B) Oxygen ?		Yes/no
Any others please give details
Do you suffer from travel sickness?			Yes/no	Can you use a ordinary seat on the bus?				Yes/no
Can you gain access to your home on return? Yes/no					How did you hear of Keep Mobile?
I am applying for Dial a Ride/Dial a Ride and Day trips. (please delete as required) I enclose enrolment fee of £1.00 plus annual subscription (where applicable) as advised by the society. I have received a copy of and agree to abide by the terms and conditions, of the society rules and amendments as they arise. I understand that the responsibility for the carrying and taking of any medication rests with me and that the above information is for emergency use only. All cheques to be made payable to Keep Mobile.
signed					Date