Online Registration

£20.00 Online Registration Fee

Personal Details

We require this information in order to provide our services to you. It is held on a secure UK database and is not shared with any 3rd parties.

Next of Kin or person to be contacted in an emergency

We make the assumption that you have the permission of this person to give us their details

Addition Information:

Folding Zimmer Frame:Non-Folding Zimmer Frame:Manual Wheelchair:Folding Wheelchair:Electric Wheelchair:Essential Escort:

I hereby give my consent to Community Connexions retaining information on my health or any other sensitive data relevant to me using their service and to disclosing my personal details in the event of an extreme emergency.

By ticking here, Yes I am giving you consent.