Step 1 of 333%TRAIN TRAINEE DETAILSTravel Trainee Name* First Last Date of birth* MM slash DD slash YYYY Home Address* Street Address City County Post Code Telephone*Gender*MaleFemaleOtherIs this a referral from an external source?* Yes NoCurrent School / College / Day service* Referal Contact Name* Referred by* Date* MM slash DD slash YYYY Referal Telephone*Referal Address* Street Address City County Post Code Referal Email* TRAVEL TRAINEE REQUIREMENTSPlease state the journey the travel trainee needs to learn (include the day and the time)*Please comment on: Medical information: Include any allergies*Additional information*Sensory/physical disabilitiesBehaviourPhobiasDoes this person currently receive transport support?* Yes NoTransport Support E.g. Taxi’sHow does this person currently travel? E.g. Private car, taxi, PTS transport.Please outline travel support needSAFETY AWARNESSCan this person:Recognise the dangers of the road?* Yes NoUse a light controlled and/or pedestrian crossing?* Yes NoCross streets safely, without using a recognised crossing?* Yes NoLearn to remember routes and directions?* Yes NoRead a bus number/destination?* Yes NoRequest help from an appropriate source?* Yes NoDeal appropriately with strangers?* Yes NoMaintain their own personal safety?* Yes NoAdditional informationDate* MM slash DD slash YYYY Name* Signature* NameThis field is for validation purposes and should be left unchanged.
