Active Adults Bus Trip Request

SENIORS BUS TRIPS APPLICATION: ACTIVE ADULTS

Active Adults is a social outings program for people 55 years of age and over living in the CIty of Canada Bay area. Active Adults trips are for people who are independently mobile and can walk at least 500 metres without walking aids or assistance.

If you have any questions please contact Council on 9911 6555.

Your Details

First Name *

Surname *

Street Address *

Suburb *

Postcode *

Email address

Mobile Number

Home phone number

Pickup Location *

DrummoyneConcordFive Dock

Emergency Contacts

Provide details of two different people we would be able to contact in an emergency.

Emergency Contact #1 Full Name *

Emergency Contact #1 Phone Number *

Emergency Contact #1 Relationship *

Emergency Contact #2 Full Name *

Emergency Contact #2 Contact Number *

Emergency Contact #2 Relationship

Other Information

Are you registered with My Aged Care? *

YesNo

What language do you speak at home? *

Please list any medical conditions/ health problems we should know about? (Including allergies)

Please list medications you are taking, if any

Please list any special requirements you may have that we should be aware of

Mobility

The Active Adults bus trips require you to be independently mobile. Please answer the following questions.

Are you able to walk without using any aids (frame, stick etc)? *

YesNo

Are you able to comfortably get on and off a bus with no assistance? *

YesNo

Can you comfortably walk at least 500m? *

YesNo

Can you comfortably use stairs with no assistance? *

YesNo

If you answered no to any of the mobility questions above, please contact Council on 02 9911 6555 to discuss if the Bay Connection Program may be more suitable for your needs.

Trip Preferences

How to book: Please place a tick next to the trips you would like to attend.

Trip Allocation:

• We will do our best to allocate your preferred trip/s, but due to high demand, places cannot be guaranteed.

• If your nominated trips are booked out, you will be placed on a waiting list and notified if a position becomes available.

• When you have been booked in for a trip, you will be sent a confirmation letter with the details.

Payments:

• Payment is required on the bus, via EFTPOS.

• If you require an alternative payment method please contact us.

Cancellation Policy: Full fees will be charged for trips that are cancelled with less than 48 hours’ notice. You will be sent an invoice for the full amount.

Declaration

I participate in these activities at my own risk.

*

I hereby indemnify and release City of Canada Bay Council, its employees and volunteers from all liability for injury, loss or damage connected with my participation in these activities.

*

I consent to receiving any medical treatment that Council staff consider desirable during or directly after the activity, and I affirm that all medical information relevant to my participation in these activities has been supplied.

*

Signature *

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Date *

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