Community Link - Stafford & District

Please fill in our 'Individuals Online Membership Application Form'

About You:

Title: (Mr/Mrs/Ms/Other)		Surname:
First Name (s):		Sex:	Male Female
Email Address:
Your Address:
Postcode:		Date of Birth:
Phone Number (day):		Phone Number (evening):
Do you receive Travel Tokens?	Yes No	If so, who issues them?
Eligibility:

Do you have a physical disability?	Yes No	Do you have a learning disability?	Yes No
Do you have a hearing impairment?	Yes No	Do you have a sight impairment?	Yes No
Are you temporarily disabled through illness or accident? If so please state:	Yes No
Do you have difficulty catching a bus?	Yes No	Do you require someone to guide/support you?	Yes No
Do you need any medicines or medical equipment with you when going out? If so, please explain what the medicine or equipment is for:	Yes No
Do you use a wheelchair? If so, which type?		Do you use a walking aid? If so, which type:
In Emergencies:

Should an emergency arise we need to know who you would like us to contact. (You should have the consent of this person to disclose these details).
Name:		Telephone Number:
Relationship (if any):

By clicking the 'submit' button, you (the customer) agree that 'Community Link - Stafford & District' can keep these details on their database until such time as your membership lapses. Data received is taken in the strictest of confidence and stored in in accordance with the data protection act.


'Community Link - Stafford & District' Registered Charity No: 1095768 A Company Limited by Guarantee No: 4549467 Registered with the Information Commissioner under the Data Protection Act.