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Member Registration Form

Annual Memberships cost £20. Please call us to arrange this payment. 2 members from the same house can join for a discounted rate of £35.

Title

First Name *

Last Name *

Date of Birth *

Street Address *

Second Line (if applicable)

Town/City

County

Post Code *

Phone Number *

Email Address *

Do you use any of the following? (If Applicable) *WheelchairShopping TrolleyGuide DogWalking AidOtherNone

Emergency Contact *

Name of Emergency Contact

Blue Badge Holder? *YesNo

What gender do you identify as? *Please SelectMaleFemaleNon BinaryOther

Bus Pass No. (If Applicable)

I consider myself disabled *YesNo

What is your ethnicity? *What is your ethnicity?Asian or Asian BritishBlack, Black British, Caribbean or AfricanMixed or multiple ethnic groupsWhite, White BritishOther ethnic group

Tick this box to confirm that this information is correct *The information I have provided is correct

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