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Office 01908 372 344

Mobile 07876 031 945

Create complex forms with ease

Your site comes with a contact form already set up but you can set up forms to be shown on any page in your site with any number of inputs. These can be made of any combination of Text (single & multi line), check boxes, radio buttons or drop down menus.

These can be individually set as obligatory fields that have to be filled in for the form to be sent.

This is an example of a form with over 60 inputs set up for a driveability supplier.

* indicates required fields

Section 1. Personal details

Title

First Name*

Surname*

Address*

Post code*

Contact Tel*

Emergency Tel

Date of birth (dd/mm/yy)*

Your weight

Your height

Section 2. Driving licence details

Type of licence

Full Prov None

Driving Licence Number

Licence expiry date

National insurance No

This is used to carry out online licence checks if necessary - Please tick the box if you consent to this

Number of years driving experience (years)

If you have a medical condition / disability have you informed DVLA?*

If yes, what is the current situation

Are there any restrictions related to your disability recorded on your licence?

If yes, please give details

Section 3. Current driving details

Are you currently driving?

If not currently driving, when was the last time you drove?

What transmission is this?

Make/model and approximate age of current vehicle

Please give details of any adaptations already fitted to your car:

Do you think you will be able to continue to drive this type of car?

Which type of transmission do you want to drive on the day of your assessment?

Section 4. NATURE OF DISABILITY OR PROBLEM(S)

If you already hold a driving licence and you develop a medical condition that could affect safe driving, then you are legally required to inform the DVLA. We may be unable to carry out the on-road drive part of your assessment if this has not been done.

Do you have any medical conditions or disabilites?*

If you know the name of your condition e.g. stroke, head injury etc, please provide details here. If you don´t have a specific condition please can you give us much information as possible about how you are affected e.g. back pain, tiredness, memory problems, problems with co-ordination.

What are your current issues with driving?

Have you been assessed by a Mobility Centre before?

If YES, which centre did this take place?

What do you hope to achieve from the Assessment?

Do you take any medication that may impact on your driving?

If YES state details

Do you have communication issues?

If YES state details

Section 5. MOBILITY DETAILS

If you receive the Higher Rate component of the Disability Living Allowance or Personal Independence Payment please call Motability on 0300 456 4566 and ask to be referred to Wessex DriveAbility for an assessment

Do you receive the Higher Rate Mobility Component of the Disability Living Allowance?

Can you walk at all?

Do you use...?

Do you require any aids when walking?

Do you have any problems getting into a car?

if yes, please give details

Any other information that may be relevant

Who is paying for the assessment?

How did you hear about us?

As part of our aim to reach everyone in the community, it would help us if you could tick one of these boxes for monitoring purposes:

We will contact you to arrange an appointment in due course if not already arranged. In order to assist us, do you have any specific days / dates or times that you are NOT available

Has this application been completed by the Client?

If NO Please state who this application was completed by and why

Section 6. Declaration

By completing and returning this Application Form to Wessex DriveAbility you are giving consent to undertake a Driving Assessment. Your consent may be withdrawn at any time. Under the Data Protection Act 1998 you have the right to enquire in writing what personal information the assessment centre holds about you and subject to status, you may be supplied with a copy of this information.

Declaration

I declare that I have checked the details I have given on this form and that they are correct to the best of my knowledge

Yes

It is important to tick the following statement:*

I fully understand that in exceptional circumstances Wessex DriveAbility may have a Duty of Care to inform the DVLA of the findings and outcome of this assessment.

I Agree

Please type code shown into box below. NB. This is not case sensitive.

Note : Personal information you submit on this form is not shared or permenantly stored.

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Office 01908 372 344

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