Lynx Test First Name *Last Name *If you have an email address, please add it hereYour Phone Number *Street Address *CityCountyPost Code *Your Date of Birth (dd/mm/yy) *Do you use a wheelchair? *Please select an optionNoYes - ManualYes - ElectricWhat is the make and model?Do you use a walking aid? *Please select an optionNoYesWhat type is it?Do you use a Guide Dog? *Please select an optionNoYesDo you need to bring someone with you? *Please select an optionNoYesWho are they? Are they a member? Do they have companion status?Do you have a South Glos Diamond Travel Card? *Please select an optionNoYesWhat is your travel pass number?What is your Travel Card Expiry Date?Do you have a Disability Blue Badge? *Please select an optionNoYesDo you pay Income Tax? *Please select an optionNoYesWould you like your membership Gift Aided?YesNoThis allows us to claim 25p for every £1 given, at no extra cost to youPlease provide details of the person to contact in case of an emergencyWhat is the phone number of the person to contact?Is there anything else you think we should know about you? Send your membership Request
