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, email or fax 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?

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We never share customer information with third parties but do occasionally contact our customers for informational or marketing purposes. If you do not want to be contacted by hoppa for such purposes please tick the box below.
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