Diamond Travelcard application form for disabled applicants Council documents can be made available in large print, audio, easy read and other formats. Help is also available for people who need council information in languages other than English. For more information contact the Diamond Travelcard Office on 01934 426 426 or email: diamond.travelcard@n-somerset.gov.uk. You can return your completed form by post to: North Somerset Council, Diamond Travelcard Office, Somerset House, Oxford Street, Weston-super-Mare, BS23 1TG. You can return it in person to: - Somerset House, Oxford Street, Weston-super-Mare (until the end of March 2009) - the Town Hall, Walliscote Grove Road, Weston-super-Mare - any North Somerset Library - the For All Healthy Living Centre, Lonsdale Avenue, Weston-super-Mare The technology involved in printing passes means that we cannot print them instantly for personal callers. However, we can accept and check application forms at any of the above locations, forms will then be forwarded to the Diamond Travelcard Office where they will be printed and dispatched. Please attach a recent passport sized photograph to your application. The photos should show head and shoulders only with no headgear. Please print your name on the back in case it gets separated. SECTION A: to be completed by all applicants SECTION B: to be completed by all applicants eligible automatically without further assessment SECTION C: to be completed by all other applicants, relevant medical evidence to be provided where required SECTION D: application for a companion Diamond Travelcard SECTION E: to be completed by all applicants SECTION F: additional information SECTION G: declaration - to be completed by all applicants *****SECTION A - PERSONAL DETAILS (to be completed by all applicants)***** -Title: []Mr []Mrs []Miss []Ms Other (please state): -First name: -Middle name(s): -Last name: -Sex: []Male []Female -Date of birth: -National Insurance Number: Address: -House name or number: -Street: -Village: -Town: -Post code: -Telephone number (including STD code): -Email address: -Previous pass number (if any): -Would you like to receive future correspondence in large print? []Yes []No *****SECTION B - ELIGIBILITY ASSESSMENT (to be completed by all applicants eligible automatically without further assessment)***** -Do you receive Disability Living Allowance at the Higher rate for mobility? []Yes []No If yes, please provide evidence, no older than 12 months, showing the period it covers. EG: an official letter confirming award of the allowance. If the award is for less than 12 months you may not qualify. -Do you receive a War Pensioners' Mobility Supplement? []Yes []No If yes, please provide evidence, no older than 12 months, showing the period awarded. EG: an official letter confirming award of supplement. If the award is for less than 12 months you may not qualify. If you answered yes to any of the questions this section, please continue to section D. *****SECTION C - OTHER ELIGIBILITY ASSESSMENT (to be completed by all other applicants, relevant medical evidence to be provided where required)***** If you answered no to all questions in section B, you will only qualify if you can answer yes to one of the following questions and provide relevant medical evidence. 1. Severe disability in both arms. -Have you lost, or do you have a long term inability to use both arms? []Yes []No Please provide details in section F and provide medical evidence to show that you meet this criteria. EG: a letter or report from a specialist. 2. Unable to hear. -Are you profoundly or severely deaf? []Yes []No -Are you registered with the council? []Yes []No If not, please provide medical evidence to confirm that you have a hearing loss of 70dbHL of above. EG: a letter or audiological report from an aural specialist. 3. Unable to speak. -Are you unable to speak, or is your ability to speak severely or permanently impaired? []Yes []No Please provide medical evidence to confirm that you are unable to make clear or basic oral requests (EG: to ask for a particular destination or fare) or are unable to ask specific questions to clarify instructions (EG: does this bus go to the town centre?) Medical evidence should be a letter or report from a specialist. People with a stammer or those for whom English is not their first language will not be eligible. 4. Blind or partially sighted. -Are you registered as blind or partially sighted with the council? []Yes []No If yes, you automatically qualify. -Are you blind or partially sighted but not registered? []Yes []No You should be unable to read the top letter on the eye test chart (used by doctors and opticians) with your glasses, if worn, at a distance of six metres or less. If not registered, then you will need to provide evidence you meet this standard in the form of a letter or report from your Opthalmologist or General Practitioner. 5. Severely disabled and unable to walk, but not yet in receipt of higher rate mobility component of Disability Living Allowance. -Do you have an existing Blue Badge? []Yes []No -If yes, when does it expire? (EG: 20 October 2008) -Are you severely and permanently or long term disabled and unable to walk? []Yes []No Your disability should be at a comparable level to that required to claim the higher rate component of the Disability Living Allowance. You will only be eligible if you can provide evidence that you walk with excessive labour and at an extremely slow pace or with excessive pain. Difficulty in carrying parcels will not be taken into account. Using a walking aid will not necessarily mean you qualify. If you can walk relatively normally with an artificial leg then you may not be considered eligible. You will need to provide evidence that you meet these criteria in the form of a letter or report from a specialist setting out a diagnosis. Alternatively we may require you to be assessed independently by one of the council's Occupational Therapists. 6. Significant learning disability. -Do you have a significant learning disability? []Yes []No A significant learning disability is a state of arrested development of the mind, which includes significant impairment of intelligence and social functioning. Those affected will have reduced ability to understand new or complex information, a difficulty in learning new skills, and may not be able to cope independently. These disabilities must have started before adulthood and have a lasting effect on development. -Are you in a residential care home? []Yes []No -If yes, please tell us which one: -Do you receive (or have you received) any services from the council's learning disabilities team or children's disabilities team? []Yes []No If you are not in a residential care home or in receipt of social services provisions but feel you have a significant learning disability you may still be eligible for a bus pass. Please return the completed application form and enclose any relevant medical evidence, EG: a letter or report from a specialist, and we will consider your application. 7. Unable to drive due to a medical condition. Medical conditions that may prevent you from holding a driving licence include types of: epilepsy, restricted visual fields, cardiac, renal or neurological disorders, or a severe mental disorder. This criteria does not apply to individuals who persistently misuse drugs or alcohol. -Have you surrendered your driving licence or had it revoked or would your application for a driving licence be refused on medical grounds? []Yes []No -If you are unable to drive due to a severe mental disorder, are you, or have you been a patient with the Avon and Wiltshire partnership? []Yes []No -Do you hold a current provisional or full driving licence? []Yes []No -Is this licence currently surrendered or recoked? []Yes []No -If yes, when can you re-apply? (date) Please provide evidence from the DVLA confirming your licence has been surrendered or revoked or evidence of your current medical condition, including any medication taken that prevents you from obtaining a driving licence. EG: a letter or report from a specialist. *****SECTION D - APPLICATION FOR A COMPANION DIAMOND TRAVELCARD***** The Diamond Travelcard partnership recognises that for various reasons, some people are unable to use buses without a companion to help them. Although not part of the National England scheme, the partner councils including North Somerset provide an additional benefit to those people by allowing their companion to travel free of charge with them in the Diamond Travelcard partnership area. This benefit is provided at the discretion of the council, and North Somerset Council reserves the right to change or withdraw this benefit at any time. Children under the age of 11 cannot apply for a companion card. -I would like to apply for a companion pass as I need the assistance of a companion at all times when travelling. []Yes This section must be completed by your GP or consultant and you will need to ask them to stamp the application with their practice stamp. -I can confirm that the applicant has a disability and is unable to travel on public transport without the aid of a companion for the duration of the journey. []Yes Name and address of GP or consultant: Telephone number: Signature: *****SECTION E: MEDICAL/PROFESSIONAL CONTACTS (to be completed by all applicants)***** This information is necessary to ensure any required checks are made quickly and with the correct GP/consultant. -In the last 12 months, have you seen anyone, apart from your GP, in connection with your illness or disability? []Yes []NO -Their name: -Their title: []Mr []Mrs []Miss []Ms []Dr Other (please state): -Their profession or specialism: -Their telephone number (if available): -When did you last see them? -Where did you see them? (please give full address) Please provide contact details for your GP. -Name: -Address: -Postcode: -Telephone number: *****SECTION F: ADDITIONAL INFORMATION***** Please tell us anything else you think we should know about your claim that isn't covered elsewhere inyour application. *****SECTION G: DECLARATION (to be completed by all applicants)***** [] I wish to apply for a concessionary Diamond Travelcard and will abide by the conditions of the scheme as detailed in the current Diamond Travelcard booklet. [] I am a permanent resident of North Somerset and the address on page 3 is my sole and principal residence. [] I agree to North Somerset Council contacting an accredited health professional if necessary for the purposeof obtaining information to support my application. [] I declare that, to the best of my knowledge, all the information I have provided is correct. Signed: Date: Data protection: This information will be used by North Somerset Council, the Department for Transport, bus operators, and appointed contractors to administer the Diamond Travelcard service and may be used to monitor bus usage. It may also be used internally for research into travel services. Your name and other identification details may also be used in the council's contact centre for the purposes of improving your access to any of the council's services. The Diamond Travelcard itself will only hold your name, pass number and expiry date. The council is under a duty to protect the public funds it administers and may use information you have provided in order to prevent and detect fraud. We may, therefore, also share this information with other bodies responsible for auditing or administering public funds for this purpose, including the Audit Comission, and the council's auditors. Please contact the council's Corporate Information Management team for any queries about data protection. ***FOR OFFICE USE ONLY*** [] Photo [] Proof of residence Proof of disability: [] HRMA of DLA [] War Pensioners' Supplement [] Medical evidence [] Other: [] Referred to OT [] Renewal [] Permanent [] Time limited: [] Companion evidence Initials: Account number: Date of issue: Account number: