For Office use only.

Membership no.

London Dial-a-Ride Eligibility A B

Application Form
Essential
Escort Y N
Media U B
CD EM
Mailing M AC

Please read the guidance notes carefully before completing the form. If you need help, an
alternative format or a telephone-based language translator please call us on 0343 222 7777.

Part One – Personal details of the applicant

Everyone must complete this section.

Please include your mobile phone number and email address if you have them.

Title: Mr Mrs Miss Ms Other:

Last name:

First name(s):

Address:

Postcode: Date of birth:

Home phone: Mobile:

Email address:

Please provide any other information about where you live that might help our drivers,
for example: ‘I live on the 10th floor’.

Which London Borough do you live in?

TfL restricted (when completed) May 2018

MAYOR OF LONDON
 Part One – Personal details of the applicant, continued

Alternative contact details.

If you want all correspondence (such as the membership pack and members newsletters)
sent to someone other than the applicant detailed overleaf please give the alternative mailing
details below.

Title: Mr Mrs Miss Ms Other:

Last name:

First name(s):

Address:

Postcode:

Email address:

Relationship to the applicant:

If you are completing this form on behalf of someone else:

One of the special features of Dial-a-Ride is the door-to-door assistance we provide. However,
unlike some council-provided door-to-door services, our buses are not staffed with passenger
escorts, so there are some differences in the level of assistance we are able to give. Our drivers
sometimes have to leave passengers alone on the bus for up to 10 minutes with the doors
open whilst they go to the home of another passenger to help them to or from the vehicle.
This means that someone who needs to be supervised must always travel with another
person (an ‘essential escort’).
If you are the carer of someone who cannot be left unattended on a bus, for example
because they are experiencing confusion, memory loss or at risk of exhibiting disruptive
behaviour whilst on their journey or when they arrive at their destination, and who will
therefore need to travel with an ‘essential escort’, please let us know by indicating on page 9
of this form that the applicant must be supervised when travelling with Dial-a-Ride.

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 Part Two – Assessment of eligibility

Section 2a Automatic eligibility

This section is for people who are automatically eligible for the Dial-a-Ride service.
You will need to provide a photocopy of a relevant document to support your application.

Please tick as many boxes as apply but you only need to provide evidence for one
(please see page 2 of the guidance notes). Choose the one that is easiest for you to provide.

I am a member of Taxicard

My Taxicard number is

I receive Higher Rate Mobility Component

of Disability Living Allowance

I receive the Standard or Enhanced Mobility

Rate of the Personal Independence Payment (PIP)

I am registered blind/partially sighted

I receive Higher Rate Attendance Allowance

I receive Mobility Supplement of War Pension

I am aged 85 or over

Please do not send original documents

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 Part Two – Assessment of eligibility, continued

Section 2b Non-automatic eligibility

This section is for people who are not automatically eligible for the Dial-a-Ride service and will
be used by our trained assessors to review your eligibility.

You will need to provide some written proof from a healthcare professional of the
mobility problems that you describe below with your application form.
Further details can be found in the guidance notes.

In the last three months, how often have you used:

Often Sometimes Never

Buses

Trains

Underground

Docklands Light Railway

London Tramlink

Choose the statement that best describes your abilities today:

I don’t have any difficulty standing

I have difficulty standing

I cannot stand

If you have difficulty in standing, how long are you able to stand?

What prevents you from standing longer?

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 Part Two – Assessment of eligibility, receipt of other benefits, support

Section 2c Non-automatic eligibility

This section is for people who are not automatically eligible for the Dial-a-Ride service and will
be used by our trained assessors to review your eligibility.

You will need to provide photocopies of relevant documents to support your application.
Please tick as many boxes as apply.

Do you receive any of the following? Medium Rate Lower Rate

Disability Living Allowance (Care)

Disability Living Allowance (Mobility)

Attendance Allowance

Enhanced Standard

Personal Independence Payment (Daily Living)

Do you have adaptations or aids provided/fitted to your home? Yes No

If yes, please explain:

Do you receive any other form of benefits or care? Yes No

If yes, please explain:

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 Part Three - To be completed by all applicants

Please tell us about any existing long-term condition or disability that you live with
and how it affects your mobility.

Please explain how your mobility problems make it difficult for you to use public
transport. Include as many factors as you feel are important (you can continue on
a separate sheet if you like).

This information will be used by Dial-a-Ride for all applicants to help us to take into account
your personal accessibility needs when you travel with us. If you are not automatically eligible
our assessors will also use this information to help confirm your eligibility, in addition to the
information you have provided in Section 2b and c.

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When travelling with Dial-a-Ride, will you be using:

Always Sometimes Never Make and model

A manual wheelchair

An electric wheelchair

A scooter

Please note that you cannot travel on our vehicles in a ‘sports style’ wheelchair.
Please note that we cannot process your application form if you have not provided us
with the make and model of your wheelchair.

Does your wheelchair/scooter have any non-standard features or attachments, or any

other adaptations we might need to know about? For example: extended footrests, tray,
oxygen bottle. Is the wheelchair/scooter very large or is it tailor-made? Please give details.

If a healthcare professional advised you to get your wheelchair or scooter please

give their name and professional position below.

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 Part Three – To be completed by all applicants

Do you: Yes No

Weigh more than 16st (103kg)?

When travelling with Dial-a-Ride, will you be using:

Always Sometimes Never

A walking frame

Sticks or crutches

If a healthcare professional advised you to get your walking aid please give their name and
professional position below:

Will you be travelling with: Always Sometimes Never

A shopping trolley

A guide dog

Can you get into: Yes Not sure No

A saloon car

A people carrier style car

A London black taxi

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 Part Three – To be completed by all applicants

Is there any other information you would like us to know when arranging
your transport?

Emergency contact details:

Is there someone we can contact on your behalf in case there is a problem with your journey
and we cannot contact you directly (eg family member, friend, neighbour)?

Contact name:

Home phone number:

Mobile (if they have one):

Relationship to you:

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 Part Three – To be completed by all applicants

Sending you information about the service
In what format would you prefer to receive information about the service?

Normal print Large print Email

USB/memory stick Audio CD Braille

If you have chosen email or USB/memory stick, we will provide information in Word, PDF and
MP3 format.

If you have chosen to receive information by email please ensure you have included your email
address on the front page

Request for any other format (please specify)

Proof of identity
You must provide proof of your identity to support your application.
Please enclose a photocopy of one of these documents

Driving licence Passport Marriage certificate

NHS medical card or GP letter

Statutory declaration of change of name

Asylum registration card (ARC) or standard acknowledgement letter (SAL)

Birth certificate (Note: if you are married and have changed your name,
you cannot use your birth certificate as proof of identity)

Please do not send original documents TfL restricted (when completed) 10

How did you hear about Dial-a-Ride?

To help us monitor the best ways in which we can make people aware of the Dial-a-Ride
service we would be grateful if you could indicate below how you heard about the service.

Health/Social Services professional

Nurse/Doctor Social worker Occupational therapist

Other (please specify)

Group or organisation

Older people’s organisation (please specify)

Disabled people’s organisation (please specify)

War Veterans’ association (please specify)

Other (please specify)

Transport for London/Dial-a-Ride publicity or contact

Dial-a-Ride bus Dial-a-Ride driver Dial-a-Ride staff (other)

Dial-a-Ride or Transport for London speaker at a meeting

Transport for London pension fund

Other (please specify)

Other

Existing Dial-a-Ride customer Department for Work and Pensions

Local council Other (please specify)

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 Privacy notice

Transport for London (TfL), its subsidiaries and service providers will use your personal
information for the purposes of customer services and administration (including assessing
and reviewing your eligibility to receive the Dial-a-Ride service), the provision of travel-related
information, customer research and fraud prevention. By providing us with your personal data,
including sensitive personal data about your health, you consent to the collection and use of any
information you provide in accordance with the purposes listed above. Your personal information
will be properly safeguarded and processed in accordance with the requirements of privacy and
data protection legislation.

In certain circumstances, TfL may also share your personal information with the police and other
law enforcement agencies for the purposes of the prevention or detection of crime.

Declaration
Please sign and date the following declaration:

I declare that the information given is true in all respects and that I am unable (or almost unable)
to use public transport services including buses, trams, London Overground and Underground
trains, some or all of the time. If any changes occur to my mobility needs I will let Dial-a-Ride
know immediately.

Signed: Date:

If you cannot sign the declaration yourself, your relative/spouse/person of authority/friend

can sign it below on your behalf. If you are under 16 years of age, your parent or legal guardian
must sign this form below.

Signature: Date:

Print name:

Relationship to you:

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 Please return this form to:

London Dial-a-Ride
PO Box 68799
London
SE1P 4RD

Final checklist

Have you included your proof of automatic eligibility if you are applying under
this criteria (page 3 of application form and page 2 of the guidance notes)?

Have you included your proof from a healthcare professional for an application
under non-automatic eligibility? (see page 3 of guidance notes)

Have you included your proof of all benefits received for an application under
non-automatic eligibility (see page 5 of the application form and page 3 of the
guidance notes)?

Have you provided us with the make and model of your wheelchair?

Have you included your proof of identity (page 10 of application form)?

Have you signed the declaration on page 12?

Have you used the correct postage? (An A4 envelope needs a ‘large’
first class stamp or it will not be delivered by the Post Office)

Please now turn over to complete the Equal opportunities monitoring form

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 Equal opportunities monitoring

Dial-a-Ride aims to provide its services in a fair and equal way to everybody in the community.
To help us with this, we ask you to please complete this section of the form. The information
you provide will only be used for the planning of services and will not be reproduced in any way
that enables you to be identified. This information will be separated from your application
form when we receive it and will not be used as part of the application process.

Are you: Male Female

Main ethnic group Cultural background

White British Irish

Any other white background (please specify):

Mixed White and black Caribbean White and Asian

White and black African

Any other mixed background (please specify):

Asian or Asian British Indian Pakistani Bangladeshi

Any other asian background (please specify):

Black or black British African Caribbean

Any other black background (please specify):

Chinese or other ethnic Group Chinese

Any other ethnic group (please specify):

Prefer not to say

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London Dial-a-Ride
PO BOX 68799
London
SE1P 4RD