CVC - Individual Membership Application Form (Ring & Ride)

Your Title

First name

Last name

Phone

Date of Birth

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

To help us to identify your transport requirements, please indicate your appropriate level of mobility

Please advise of any medical conditions that we should be aware of to ensure a comfortable and safe journey. e.g. arthritis, heart condition, vertigo

Companion Name if applicable:

Emergency Contact Name

Emergency Contact Number

Relationship to you

Please tell us about anything else you think we should know

Individual Membership is *Free per year. - TBC

Mileage charge 45p per mile or £5 per round trip

By submitting this application you acknowledge that you agree to the terms and conditions as stated here.

Date of Application

Day

Month

Year