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01274 725 012

07963 511 771

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Application Form – Travel Assistance Training

Step 1 of 3

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TRAIN TRAINEE DETAILS
Travel Trainee Name*
First Last
Date of birth*
MM slash DD slash YYYY
Home Address*
Street Address City County Post Code
Telephone*
Gender*
Is this a referral from an external source?*
- Yes
- No
Current 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 REQUIREMENTS
Please 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 disabilities
Behaviour
Phobias
Does this person currently receive transport support?*
- Yes
- No
Transport Support E.g. Taxi’s
How does this person currently travel? E.g. Private car, taxi, PTS transport.
Please outline travel support need

SAFETY AWARNESS
Can this person:
Recognise the dangers of the road?*
- Yes
- No
Use a light controlled and/or pedestrian crossing?*
- Yes
- No
Cross streets safely, without using a recognised crossing?*
- Yes
- No
Learn to remember routes and directions?*
- Yes
- No
Read a bus number/destination?*
- Yes
- No
Request help from an appropriate source?*
- Yes
- No
Deal appropriately with strangers?*
- Yes
- No
Maintain their own personal safety?*
- Yes
- No
Additional information
Date*
MM slash DD slash YYYY
Name*
Signature*
Comments
This field is for validation purposes and should be left unchanged.

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01274 725 012

07963 511 771

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