Home support passengers drivers join the club contact us whatisit

Home support passengers drivers join the club contact us whatisit

Home support passengers drivers join the club contact us whatisit

Application to ‘Join the Club’

To make use of this voluntary service members of the community who have no or limited access to public transport or car must complete an application form to become a member of the Scheme. There is no charge to join the club but the journeys are carried out at a set table of fees.

Application to join the scheme as a passenger

Name of applicant  ……………………………………………………………………………………….

Address (including postcode)  …………………………………………………………………………………………..

….......................................................................................................................................................................................................................................

  

  

Home phone number  ……………………………………………………………………….

Mobile phone number …………………………………………………………………..

Email address: ……………………………………………………………………………………………………..  

Next of Kin ………………………………………………………………………

Name  …………………………………………………………

address  ………………………………………………………………………………………………………..

….......................................................................................................................................................................................................

  

  

Contact phone number(s)  ……………………………………………………………………………………………

How mobile are you? Please tick appropriate box

Can you walk and get in and out of a car?

 

Yes without assistance  

Yes with a little assistance  

No I am unable to  

No but I would travel with my carer  

Do you posses a Blue Badge (disabled) ?  Yes /No

What would you need transport for? Please tick appropriate box

Hospital visit

Doctors visit

Others please give details   

   

If your appointment is to be of a short duration the driver will remain with you. However, if the appointment might last several hours, in the case of treatment, the driver cannot wait and suitable return arrangements will have to be made, either by you or with us for another driver to collect you.

If you require a one-way journey then you will be expected to pay for the return journey for the driver.

The whole scheme relies on the availability of drivers who are able to offer you the service that you need.

Do you understand that you will be asked by the driver to pay a set fee for any journey based on the mileage from your home to your destination and return? YES/ NO

You will be told what the set fee is when we confirm that we can provide transport for you on each occasion.

Any additional amounts over and above the fee (and any necessary parking fees) will help the scheme to provide the service for other passengers. The driver will receive small amount for their mileage.

Do you understand that any parking fees will have to be paid to the driver? YES / NO

If you have a carer to accompany you there will be no extra charge, you will be paying for the journey not the number of passengers in the vehicle.

The vehicle you will be travelling in is owned by the driver and is not a licensed taxi cab, there are no special seats, for example for disabled travellers.

The driver will have been checked by the D.B.S. system and relevant third party insurance is in force.

Bookings should always be made usually one week in advance and once a driver has been allocated you will be informed of his name and the fee for the journey. Please be ready for the driver at the agreed pick up time.

It would be useful if you have the cash for the fee with you since the driver is unlikely to be carrying change with him / her.

The driver is unable to accept cheques or credit / debit card payments.
Any donations will be passed onto the scheme and gratefully received.

What would you need transport for?

Please tick appropriate box

Hospital visit                    Doctors visit                     

Others  medical appointments please give details   

   

NOT A TAXI SERVICE

It must be pointed out that this scheme is NOT a taxi service.

The information contained in this form will only every be used within the scheme and never passed to any third parties, By signing here you are agreeing to this being done.

Signature …………………………………       Date  ……………………………………

Please return completed forms to Eccleshall Community Car Scheme, 25 Wheelwright Drive, Eccleshall, ST21 6LB.

Printed copies of the forms can also be obtained from the pharmacy, Crown Surgery and the library.