Travel Buddy Referral

Your contact details

First Name *

Last Name *

Address *

Address

Address Line 1

Address Line 2

Town/City

County

Postcode

Email *

Telephone Number *

Mobile Number

About you

Gender * Gender

Date of Birth *

Who do you live with?

How did you hear about us?

Have you had any travel training before? *

Medical Needs

We need this information to make sure you are safe

Do you have any physical or behavioural support needs? E.g. becoming worried, angry or upset.

Do you have any allergies or phobias?

What journey you would like to learn and why? Perhaps you are planning to attend college/ work experience or a volunteer opportunity.

Travel Questions

Do you have a bus pass? *

Yes

No

Not sure

Are you aware of dangers and hazards that can arise when travelling? *

Yes

No

Not sure

Can you learn travel routes and remember directions? *

Yes

No

Not sure

Do you know how to cross at traffic lights and do you know what green and red indicates? *

Yes

No

Not sure

Do you know how to use zebra crossings and traffic islands? *

Yes

No

Not sure

Can you safely cross a road without a traffic crossing? *

Yes

No

Not sure

At the bus stop, can you read timetables and recognise the bus you need? *

Yes

No

Not sure

Would you know what to do if you got lost and who to ask for help? *

Yes

No

Not sure

Are you aware of dangers or hazards that can arise when out in the community? *

Yes

No

Not sure

Referral

Referred by Name

Referred by Date

Photo/Film Consent

We often take photos/film as part of the course and use them to help us with publicity and to show the Big Lottery what we have been doing.

Photo/Film Consent

I give permission for photos/film