Loading
Eastern Bay Accessible Transport Charitable Trust
Service User Registration Form
Purpose
This registration form is used solely for the purpose of collecting information necessary to:
• Register users of the Eastern Bay Accessible Transport Charitable Trust services; and
• Ensure service users have a safe, beneficial and pleasant experience.
You will only be asked to provide this information once when you register.
Service User Privacy
All information is obtained only for the purposes of registration for, and using, the community transport service. Personal details are protected and managed under the Privacy Act 2020, which rules how organisations, government departments and businesses can collect, store, use and share your information.
The Act ensures that:
• You know when and why your information is being collected;
• Your information is used and shared appropriately;
• Your information is kept safe and secure; and
• You can access the information an organisation holds about you.
Under the Privacy Act, you can ask for information that Eastern Bay Accessible Transport Charitable Trust hold about you, and to correct it if it’s wrong.
For more information see
Your right to know Information sheet (privacy.org.nz)
Registration Information
Personal Details
Your name
*
First name
Last name
Your address
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Home phone
Cell phone
Email address
Gender Identity
Female
Male
Non Binary
Prefer not to say
Date of Birth
*
Ethnicity - tick all boxes that apply you
European
Māori
NZ European
NZ – Other
Other / Prefer not to say
If you feel an Ethnicity Option is missing from the above list, please provide this data below:
Other Ethnicity?
Pick up Details
Are there any access issues for our vehicle to reach your house (for example steep driveway/shared driveway etc.)?
Do you have dogs on your property
No
Yes
Relevant Health Conditions
Do you have a disability?
No
Yes
If YES, please provide brief details of your disability and any assistance requirements that you have
If YES, will a carer be travelling with you on the vehicle?
No
Yes
Are there any other health conditions that we need to be aware of?
Are you a Total Mobility Card holder?
No
Yes
Emergency Information
Contact person in the event of an incident or emergency
Emergency Contact Phone Number
Journey Purpose
The following questions are not compulsory to answer, but doing so gives us a much better opportunity to design our future services against the needs of customers.
What is the main purpose of you using the transport service?
Are there other purposes for your journey/s?
If the transport service was not available, how would you, travel instead?
Bus
I would not be able to travel
lift in a car
Mobility Scooter
Taxi
Thank you for participating in the registration process. Please contact our team to make a booking on 027 407 7526
Please check the highlighted fields
✔
✘