Register

Register with our scheme

To confirm your eligibility for our schemes you will need to register your details. This can be carried out on line by clicking the link below or alternatively if you would prefer to register by telephone you should contact our coordinator on 01752 690444.

CONFIDENTIALITY – All of the information provided will be kept in the strictest confidence and will not be shared with any other parties.

Please fill out the below form or download the Application Form here and post it back.

Registration Form

First Name*
Surname*
Address*
Town*
Parish*
Post Code
Telephone*
Mobile
Date Of Birth
Email address
Are you registered disabled?*
Do you require an escort?*
Do you have any health problems?*
Do you use wheelchair or walking aids?*
- No
- Wheelchair User
- Shopping Trolley
- Taillift User
- Stroller
Seating Requirements*
Name of Kin*
Contact phone number (Next of Kin)*
Any other information
How did you hear about us?

A copy of your completed application form will be forwarded to your email address.