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In order to use our services, you will need to register with us; using the form below.

Once completed, we will inform you of your membership number by post or via email.

(fields mark with * are required)

Title*

First name*

Last name*

Date of birth *

Day

Month

Year

Address

Building number / Name*

Address line 1*

Address line 2 *

City / Town*

Postcode*

Phone number*

Email address

Please specify any disabilities

Emergency contact details

First name of your emergency contact *

Last name of your emergency contact *

Telephone number of your emergency contact *

Email address of your emergency contact

Mobility aids

Do you require a wheelchair?*

Yes

No

Is the wheelchair crash test marked (as pictured)? *

Yes

No (cannot be transported)

N/A

What type of wheelchair is it? *

Powered

Manual

N/A

Do you require the use of a mobility scooter?*

Yes

No

Do you require the use of a tri/ quad walker *

Yes

No

Do you speak, read and understand any other language (except English) ?

No

Yes

Sexual Orientation

Religious Beliefs

Ethnicity:

Asian or Asian British

Any other Asian ethnic background (please describe)

Black, Black British, Caribbean or African

Any other Black, Black British, or Caribbean background (please describe)

Mixed or multiple ethnic groups

Any other mixed/ multiple ethnic background (please describe)

White

Any other white background (please describe)

Any other Ethnic group (please describe)

The personal data you provide on this form will enable us to provide you with a safe service. We will not share this data with anyone outside VEST Community Transport unless we have reason to believe your safety is at risk. VEST Community Transport will retain this information in its databases for as long as you are a customer, or will delete it if there has been no interaction for 2 years. For further information on how we use your personal data please visit our website www.vestcommunitytransport.com or telephone 02920 490325. You have the right to withdraw this consent at any time by telephoning our office, emailing or writing to us.

I consent to VEST Community Transport processing and using my personal data in order to provide safe transport services.

I declare that the information I have provided in this form is correct at the time of completion. I agree to notify VEST is my circumstances change in relation to my eligibility to use this service.

Signature

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Let’s Work Together

Get in touch so we can start working together.

First Name

Last Name

Email

Message

Thanks for submitting!

Your Transport Companion

02920 490325

enquiries@vest.org.uk

VEST Community Transport
Unit 45 Portmanmoor Rd Ind Est
Cardiff
CF24 5HB

Accessibility Statement

Terms & Conditions

Created by: Krystian Maciejczyk

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