Dublin North East Inner City & East Wall - Health Route Pilot - Membership Form
A Joint Partnership Initiative between The North East Inner City Initiative & Vantastic
Part One - Eligibility
This must be completed by all applicants. It gives us information about you so that a decision can be made about whether you meet the criteria for the Dublin North East Inner City & East Wall Health Route Pilot
Eligibility *
Please tick to confirm
Part Two - Passenger Details
Full Name *
Your answer
Date of Birth *
Gender *
Address *
Your answer
Telephone (mobile number preferred) *
Your answer
E Mail
Your answer
Mobility Aids
Please mark as appropiate
Part Three - Emergency Contact Details
Please give us details of Someone we could contact on your bahalf in case of an emergency, or if we are unable to contact you directly
Contact Name *
Please give full name please
Your answer
Contact Number *
Mobile is best
Your answer
Relationship to you *
Your answer
Part Four - Payment Details
We require full payment details before any journeys can be booked and undertaken
As above in Part Two (Membership Details) *
If No complete below
Full Payment name
Your answer
Invoice & Statement Address
Your answer
Payment Telephone / Mobile
Your answer
Payment E-Mail
Your answer
Part Five - Information to help us help you
Where did you hear about Dublin North Inner City & East Wall Health Route Pilot (a joint partnership initiative between Dublin City Council & Vantastic) *
Your answer
Dublin City Council & Vantastic will not collect any personal information about you on this Form without your permission. Any personal information supplied will be treated as confidential.

Dublin City Council & Vantastic does not routinely collect personal information about you, except for information you volunteer by completing a feedback form or by requesting a service.

We will use any personal information supplied only for the intended purpose and we will not pass your personal details on to any third parties.

In submitting this form I am declaring that the information given is complete and true in all respects
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