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