Membership Application

Individual Membership Application

Individual membership is open to anyone who is disabled or over the age of 70 living in the areas covered by Bracknell Forest or Wokingham Borough Council. Self-certification is all that is needed, there is normally no independent evidence required.

Use this form to apply for membership on line. We will endeavour to respond to you within one working day. At which time, assuming your application is successful, we will ask for payment which can be made by cheque, BACS or credit/debit card over the phone or in our office.

More information on membership including registration and subscription fees can be found here where you can download our Membership Pack. If you prefer to send us a paper application the pack contains a Membership Application form.

Click Next to complete the form.

Contact Details

Your details

Title*

First name*

Surname*

Forename(s)*

Date of birth*

Address*

Post Code*

Telephone*

Mobile

Email

Would you like correspondance to go to a different address? Yes No

Correspondance address*

Emergency contact

Name

Address

Telephone

Relationship to you

About You

Bus pass

Do you have a bus pass? Yes No

Bus pass number*

Bus pass expiry date*

Does your bus pass include a companion? No Yes

Health

Do you have a long term illness or disability? Yes No

Please give details*

Do you take any medication? Yes No

Please give details*

Do you have any dietary requirements? Yes No

Please give details*

Other

We need to know your ethnic group (for funding) and would appreciate it if you could select it form the list below.

What is your ethnic group?

How did you hear about Keep Mobile?

Travel Requirements

Declaration

I acknowledge that once my application is approved I will be required to pay an enrolment fee of £1.00 plus an annual subscription as advised.

I confirm that I have read and agree to abide by the Terms and Conditions of membership.

I confirm that I have read and agree with the Privacy Policy for Members of Keep Mobile.

I understand that the responsibility for the carrying and taking of any medication rests with me and that the above information is for emergency use only.

I understand that membership does not guarantee transport.

I confirm that I am unable to gain access to mainstream transport due to my disability or I am over the age of 70.
Should this not be the situation transport will be terminated immediately.

I am applying for*

I confirm that the information I have provided in this form is correct to the best of my knowledge.

Please check this box to confirm your application*

I wish to pay by credit/debit card

Thank you!

Your membership application has been submitted successfully. We will do our best to get back to you within one working day. If you have entered an email address we will respond by email. Otherwise we will get back to you by phone.

The Keep Mobile Team

Individual Membership Application

Contact Details

Your details

Emergency contact

About You

Bus pass

Health

Other

Travel Requirements

Travel aids

Other

Declaration

Thank you!

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