• Please use this form if you are under 65 years old.
• If you are over 65 years old, please do not complete this form. Instead, you can register by phoning My Aged Care on 1800 200 422 or phone Community Transport for more information on 4474 1040.

Required fields are marked with an asterisk (*).

Your details

Title (eg Mr, Ms, Mx, Dr) *

First name *

Surname *

Gender *

Date of birth *

• Please only proceed if you are under 65 years old.
• If you are over 65 years old, please do not complete this form. Instead, you can register by phoning My Aged Care on 1800 200 422 or phone Community Transport for more information on 4474 1040.

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Are you Aboriginal or Torres Strait Islander? *

• Yes, Aboriginal
• Yes, Torres Strait Islander
• Yes, both
• No

Home address *

Phone number *

Email address

What language do you speak at home? *

What is your country of birth? *

Assistance required

Do you require language/communication assistance? *

• Yes
• No

Do you require any mobility aids or assistance?

If none of these apply to you, skip to the next question.

• Walking stick/cane
• Scooter
• Guide dog
• Wheelchair
• Physical help

Do you have any of these health concerns that may be relevant when travelling with Community Transport?

If none of these apply to you, skip to the next question.

• Vision or hearing
• Allergies
• Vertigo
• Limited mobility
• Need for extra comfort
• Chronic pain
• Seizures

Are you able to get from your home to a car or bus? *

• Yes
• No

Are you able to get in and out of a car or minibus unassisted? *

• Yes
• No

Are you able to manage alone once you are at your destination? *

• Yes
• No

Do you need someone to travel with you? *

• Yes
• No

Existing services/pensions

Do you receive any government-funded services? *

• Yes
• No

If yes, what type of pension do you receive?

Aged pension/Pension number

Disability

Homecare/NDIS/other package provider

Do you receive a Veteran Affairs Pension? *

• Yes
• No

Gold Card number

White Card number

Your emergency contacts

Emergency contact full name

Relationship to you

Emergency contact phone number

Your accommodation

Accommodation setting *

• Boarding house
• Crises, emergency, or transition accommodation
• Independent living unit
• Private residence - owned by/being purchased by you or your family
• Private residence - private rental
• Private residence - public rental
• Supported accommodation

Living arrangements

• Single (person living along)
• Couple
• Couple with dependant/s
• Sole parent with dependant/s
• Unhoused/no household
• Group (related adults)
• Group (unrelated adults)
• Other

Declaration

Consent and privacy statement: *

• Personal information we collect from you will be for our records only.
• When you use our service, we will tell you why we are collecting information from you.
• You have the right to access your own records.
• Only relevant information will be collected.
• We may submit statistics to funding bodies.
• We will only ask you for information that is directly relevant to the services you accept from us.

• I agree with the outlined terms and conditions, Terms of Service, and Privacy Policy.
• I understand that the information I have provided is correct. I understand that my application will be assessed, and I will be notified if I am eligible for the service and accepted as a member of Council's Active Living service.
• I understand that Council's Active Living service will retain my personal information on file for the purpose of providing me with a safe service.
• I am aware that, should my circumstances change, I can discuss service and costs with staff.