Safer Places Scheme - Service User

Service User Details

Steps:

Title:

First Name(s):

Surname:

Address Line 1:

Address Line 2:

Town / City:

Postcode:

Email:

Home Phone Number:

Mobile Number:

Date of Birth:

Gender:

Special Needs (primary diagnosis):

Ethnicity:

If you are completing this form on behalf of someone under the age of 18 please click here:

If you are under the age of 18 then your parent or guardian must sign this form on your behalf.

Parent/guardian Name:

Contact Number:

Relationship to Service User:

Parent/Guardian Email:

If you are under 18, then the Safer Places Scheme can only be used in respect of your travel to and from school or other journeys that you are fully able to make independently having received independent travel training from one of the below.

For vulnerable people between the ages 11 – 18:

As this applicant is for a vulnerable person between the ages 11 – 18 years, as a parent/guardian/carer I confirm that the vulnerable person has received independent travel training from::

Trainer	Please tick as appropriate and then enter details
Wakefield Council’s Indepedent Training Team
school/college; and this can be confirmed by contacting: on email:
a relative/carer; and this can be confirmed by contacting: on email: