Register

hoppa Club Application Form

To use a hoppa service (with the exception of the Scheduled services) you must first register as a member. Registering is FREE and can be done below or by calling us on 01428 681701 and asking us to post or email you a registration form.

Required information from applicants

All information will be treated confidentially and in accordance with the Data Protection Act 1998.

Section A - Contact Information

Name

Address

Postcode

Date of Birth (dd/mm/yy)

Telephone Number

Mobile Number

Email

Who should be contacted in an emergency?
(Please enter their name, relationship to you and telephone number.

Section B - Please tell us why you would like to join the hoppa Club. Choose one or more from the following selection.

Section C - Mobility Information

Do you use a wheelchair?

Manual or Electric?

Can you transfer to a vehicle seat?

Will a carer escort you?

Do you use a walking aid?

Do you have an illness, disability or difficulty that you wish to disclose so that we can better assist you and cater for your needs?

From time to time we would like to send you information about changes to our services and other general news and events concerning hoppa. Due to changes in Data Protection Legislation, we are now obliged to seek your permission to contact you, in order for us to do this please opt in by ticking one or more of the contact methods below*

By post
By phone
By Email
*You can unsubscribe or opt out at any time by contacting us by phone, email, post or text.

We will never share your data with any other organisations or individuals, and are committed to keeping your data safe and secure. We want you to know exactly how our services work and why we need your registration details; our Data Protection Policy can be viewed on our website at www.hoppa.org.uk or you can request a copy by calling 01428 681701

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