Individual Travel Membership Form
First Name *
Your answer
Last Name *
Your answer
Address 1 *
Your answer
Address 2 *
Your answer
City *
Your answer
Post Code *
Your answer
Home Telephone Number *
Your answer
Mobile Number
Your answer
Email
Your answer
Please tell us what makes you eligible to use our service: (e.g. difficulty in walking, heart condition)
Your answer
Will you need to travel in a wheelchair?
Do you use a walking aid?
Who can we contact if there is a problem whilst you are travelling with us? (e.g. relative or friend)
Your answer
First Name
Your answer
Last Name
Your answer
Address 1
Your answer
City
Your answer
Postcode
Your answer
Telephone Number
Your answer
Mobile Number
Your answer
Data Protection: Under the data protection act, we need your permission to store and use the information that you have provided on this form, solely for easy-go CT purposes. By ticking 'YES' below you agree to this use. Thank you. Please note it is our policy not to publish telephone numbers. *
Required
Invoice Details
If your main address is not your invoice address please continue and fill in the rest of the form.
Invoice Name
Your answer
Invoice Address
Your answer
Post Code
Your answer
Phone
Your answer
Email
Your answer
It is now a standard part of any grant and funding application to have a section asking for information about ethnic origin, the gender and the age span of our members. In order for easy-go CT (Stockport) to be able to provide these numbers will you please consider completing the questions below by simply ticking the relevant boxes. Please note it is not compulsory for you to complete this section. If you wish not to complete this section please leave blank, scroll down to the bottom of the page and click the SUBMIT button.
How would you best describe your ethnic group?
Gender
Decade of Birth
Please let us know how you found out about EasyGo CT? *
Many thanks for registering and completing our form, please click the SUBMIT button to finish.
Submit
Never submit passwords through Google Forms.
This form was created inside of TOUR.MEDIA.