Vantastic Membership Form - Individual
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 Vantastic criteria for Membership
Eligibility *
Please tick most appropiate
Required
Part Two - Membership Details
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Address *
Telephone (mobile number preferred) *
E Mail
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
Contact Number *
Mobile is best
Relationship to you *
Part Four - Billing Details
We require full billing details before any journeys can be booked and undertaken
As above in Part Two (Membership Details) *
If No complete below
Full billing name
Invoice & Statement Address
Billing Telephone / Mobile
Billing E-Mail
Part Five - Information to help us help you
Where did you hear about Vantastic *
Confirmation of Vantastic Privacy Statement
I confirm that I have read and agree to the Vantastic Privacy Statement *
Required
Sign Off
By typing you name below you are electronically certifying this Membership Form just as if you would physically sign it if it was on paper.
Full Name *
Submit
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