Registration Form (Please print before completing)
All information you give us is confidential
Title (Tick)

Mr

 

Mrs

 

Ms

 

Miss

 

Other

 

Surname

 

First Name

 

Address

 

Date of Birth

 

Telephone

 

Post Code

 
Are you registered disabled

Yes

 

No

 

 

Type of disability  
Would you have any of the following when travelling (please tick)

Wheelchair

 

Zimmer Frame

 

Guide Dog

 

 

Shopping Trolley

 

Baby or Toddler

 

Push Chair

 

Accompanied by an Escort

 

Other (Please Specify)

 

Local Authority Bus Pass Number

 

Please give the name and number of a relative or friend we can contact in an emergency:
 
I apply to South Somerset C.A.T. and agree to abide by its conditions of registration and carriage.

Signature

 

Date

 

Please return completed form to:

RING & RIDE SCHEME
Balsam Centre,
Balsam Park,
Wincanton,
BA9 9HB