Individual Membership Application
Individual membership is open to anyone who is disabled or over the age of 70 living in the areas covered by Bracknell Forest or Wokingham Borough Council. Self-certification is all that is needed, there is normally no independent evidence required.
Use this form to apply for membership on line. We will endeavour to respond to you within one working day. At which time, assuming your application is successful, we will ask for payment which can be made by cheque, BACS or credit/debit card over the phone or in our office.
More information on membership including registration and subscription fees can be found here where you can download our Membership Pack . If you prefer to send us a paper application the pack contains a Membership Application form.
Click Next to complete the form.
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Title*
Mr
Mrs
Miss
Ms
Other
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We need to know your ethnic group (for funding) and would appreciate it if you could select it form the list below.
What is your ethnic group?
Please select
White British
White Other
White Irish
Mixed Race
Indian
Pakistani
Bangladeshi
Other Asian
Chinese
Black Caribbean
Black African
Black (other)
Other
Prefer not to say
How did you hear about Keep Mobile?
Please select
Word of mouth
Leaflet/Poster
Clinic/Doctors/District nurse
Social Services
Day/resource centre
Press article
Internet/Google
Other/Not known
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Travel aids
Please note that mobility scooters cannot be accommodated
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Declaration
I acknowledge that once my application is approved I will be required to pay an enrolment fee of £1.00 plus an annual subscription as advised.
I confirm that I have read and agree to abide by the Terms and Condition s of membership.
I confirm that I have read and agree with the Privacy Policy for Members of Keep Mobile.
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.
I understand that membership does not guarantee transport.
I confirm that I am unable to gain access to mainstream transport due to my disability or I am over the age of 70. Should this not be the situation transport will be terminated immediately.
I am applying for*
Please select
Dial a Ride only
Dial a Ride and Day Trips
I confirm that the information I have provided in this form is correct to the best of my knowledge.
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Thank you!
Your membership application has been submitted successfully. We will do our best to get back to you within one working day. If you have entered an email address we will respond by email. Otherwise we will get back to you by phone.
The Keep Mobile Team
