Goldfields Registration

WHEELCHAIR ACCESSIBLE TRANSPORT FOR PEOPLE WITH DISABILITY IN THE GOLDFIELDS

Wheels for Hope’s Goldfields Wheels program offers an alternative approach to wheelchair accessible transport for people with disability in the Goldfields to not only attend appointments and services but also to visit family, attend events and enjoy all the features of the local community and further afield. The vehicle is available to support anyone living in the Goldfields requiring Wheelchair accessible transport

USING GOLDFIELDS WHEELS

The vehicles are available to support anyone who requires transportation in a “transport approved” mobility device. Eligible individuals can register for the program by completing the Registration Form. Once registered and approved, bookings can be requested by emailing goldfields@wheelsforhope.org.au or calling 1300 922 115.

COSTS

There is no cost to use the Goldfields Wheels vehicle – however you will be required to refuel the vehicle before returning it. You will be required to pay for any damage incurred or excessive cleaning costs where applicable. In addition, the authorised driver is responsible for any traffic or parking infringements incurred. A valid credit card is required for pre-authorisation of a bond when making your booking.

EXTENDED TRAVEL REQUESTS

If you require the vehicle for more than 72 hours (3 days), special approval is required.

Register now!

Contact Information

PERSON MAKING BOOKING

Surname *

First Name *

Address *

Phone *

Email *

WA Drivers License Number

MAIN AUTHORISED DRIVER

As Above

Main Driver's Surname *

Main Driver's First Name *

Main Driver's DOB *

Main Driver's License Number *

Main Driver's License Expiry Date *

Main Driver's Address *

Main Driver's Phone *

Authorised Driver's Signatory

Main Driver's Email *

ADDITIONAL DRIVER

ADD ADDITIONAL DRIVER

Declaration

I hereby make application to Wheels for Hope and understand the Application is subject to the terms and conditions. I hereby agree that only registered and approved drivers are authorised to drive a Wheels for Hope Vehicle, and to pay any costs incurred including any traffic infringement penalties and any damage to the vehicle and that a $2500 excess applies in the event that the vehicle is damaged and an insurance claim is made. I will provide a valid Credit Card, to be used as security for all bookings. All drivers must be over 25 years old and hold a valid WA Driver’s licence. The vehicle must be collected and dropped off at the nominated location, and refuelled prior to return.

Signature of Authorised Person *

Clear Signature

Name of Signatory *

Date of Signature *

Supported by

So much of what we do is achieved thanks to the kind support of our key sponsors. Without their help we wouldn’t be able to keep our wheels turning.