Blaenau Gwent Car Scheme

Published: 01 December 2021

Please click on link to download the referral form.

/_UserFiles/Files/Car Scheme Referral Form 2021.pdf

Referral Form: Blaenau Gwent Car Scheme

The Blaenau Gwent Car Scheme is for people who face barriers accessing other forms of transport or need some extra support in getting to medical appointments.

Please return this form to: bgcarscheme@bridgescentre.org.uk

About the person being referred………..

Miss/Ms/Mrs/Mr First Name:…………………... Last Name:…………………………….

Address:………………………………………………………………………………………..

Postcode:…………………… Tel No:………………………….. DOB:…………………….

Emergency contact name: (if available) ……………………………………………….

Emergency contact number: (if available)……………………………………………..

Mobility

Do you use a walking stick, mobility aid or wheelchair? If yes specify what type of aid is used and when.

…………………………………………………………………………………………………

Are you able to get in and out of a car independently? Yes/No ( if no give details)

…………………………………………………………………………………………………

Additional information

If you have any memory problems or a diagnosis of dementia, what help could we give to make your journeys easier( eg reminder calls)?

…………………………………………………………………………………………………

Please give details about parking and access to your home which could be helpful to our drivers.

…………………………………………………………………………………………………

Do you have a current Blue Badge Parking Permit Yes/No Expiry date:……

A charge of 45 pence per mile and a £1 booking fee will be made to cover your driver’s expenses. This will payment will be taken as a debit/credit card payment over the phone. Please state who we should call in order to take payment.

Name:………………………………. Tel:.....................................................

Has the person you are referring agreed for us to contact them to discuss the befriending scheme.

Yes No

About you, the referrer……

Your Name:

Agency:

Address:

Postcode: Tel No: email:

Referrer’s signature:

Date: