Community Link - Stafford & District

Please fill in our 'Group Membership Application Form'

About the Organiser:

Title: (Mr/Mrs/Ms/Other)		Surname:
First Name (s):		Sex:	Male Female
Email Address:
Address of Organistation:
Postcode:
Phone Number (day):		Phone Number (evening):
Do your residents receive Travel Tokens?	Yes No	If so, who issues them?
About the Organisation:

Name of Organisation Transport is provided for:
Name of Organisation to be invoiced:
Person/Job Title responsible for payments:
Address to which invoices should be sent:
Post Code:
Telephone No:
Eligibility:

We need to know the range of disabilities you cater for, could you please answer the following:
Physical disability?	Yes No	Learning disability?	Yes No
Hearing impaired?	Yes No	Sight impaired?	Yes No
Mobility:

Do any of your residents require assistance to get around?			Yes No
Do they require some to travel with them?			Yes No
Do they take any medical equipment when they go out?			Yes No
Do they need medication when they go out?			Yes No
In Case Of Emergency:

Should an emergency arise we need to know who you would like us to contact.
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.


Thank you for your help in providing this information. Should an individual wish to use our 'Dial-A-Ride' or 'Community Car Schemes' an individual membership form must be completed. They can either be filled in online, downloaded, or we can arrange to post some out to you.

'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.