Become a Member - Worcester Wheels

Salutation: *

Name *

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Last

Address: House/Flat Number and Street: *

Address: Post Code, City/Town: *

Telephone Number: *

Mobile Phone:

Email:

Email

Confirm Email

Date of Birth *

Contact Details in Case of Emergency: *

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Last

Relationship to You: *

Emergency Telephone Number: *

Tell us about your Mobility/Disabilities/Illnesses: *

* If you selected any of the above, Please specify so we can meet your needs: *

Are you able to get in and out of a car? *

Are you able to climb few steps on and off a bus? *

Any other information you think might help us meet your needs? (I.e travel with a guide dog, seat belt exeption etc):

Have you got a BUS PASS? *

Your BUSS PASS Number if present:

GDPR Agreement *

I consent to having Worcester Wheels securely store my submitted information so they can respond to my inquiries.