Vantastic Membership Form

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Vantastic Membership Form - Individual

Part One - Eligibility

This must be completed by all applicants. It gives us information about you so that a decision can be made about whether you meet the Vantastic criteria for Membership

Eligibility *

Please tick most appropiate

Person with a Disability

Older Person (65 plus years of age with mobility difficulties)

Required

Part Two - Membership Details

Full Name *

Date of Birth *

YYYY

Gender *

Address *

Telephone (mobile number preferred) *

E Mail

Mobility Aids

Please mark as appropiate

Electric Chair

Manual Chair

Wheelchair Transfer

Walking Frame

Walking Stick or Crutches

Guide Dog

Personal Assistant

Part Three - Emergency Contact Details

Please give us details of Someone we could contact on your bahalf in case of an emergency, or if we are unable to contact you directly

Contact Name *

Please give full name please

Contact Number *

Mobile is best

Relationship to you *

Part Four - Billing Details

We require full billing details before any journeys can be booked and undertaken

As above in Part Two (Membership Details) *

If No complete below

Full billing name

Invoice & Statement Address

Billing Telephone / Mobile

Billing E-Mail

Part Five - Information to help us help you

Where did you hear about Vantastic *

Confirmation of Vantastic Privacy Statement

https://vantastic.ie/privacy/

I confirm that I have read and agree to the Vantastic Privacy Statement *

I agree

Required

Sign Off

By typing you name below you are electronically certifying this Membership Form just as if you would physically sign it if it was on paper.

Full Name *

Submit

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