freedom pass application form.pdf

7/30/2019 freedom pass application form.pdf

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Application orDisabled Persons

Freedom Pass

www.hillingdon.gov.uk

I you would like this publication inlarge print, Braille or on audio tape, or

you would like inormation about thisdocument or council services in your

own language, please call01895 556633

6. Has a learning disability which includessignificant impairment of intelligence andsocial functioning.

7. Would be refused a driving licence due to

physical disability, eg epilepsy, suddenattacks of giddiness/fainting.

How to complete the form:Part A, Part B and Part D must be filled in by allapplicants* those sections are compulsory. Ifyou answer no to all questions in Part B, or youhave answered yes to 3.3 or 7.2, you MUSTanswer Part C.

To enable us to carry out an assessment of your

eligibility for a Freedom Pass, it is important thatyou answer all relevant questions as fully aspossible and include copies of any supportingdocumentation, as incomplete forms will bereturned to you for completion and thereforedelay your application.

* The ethnic monitoring form in Part A is optional.

What is a Freedom Pass?

The Freedom Pass for people withdisabilities gives concessionary travel

on most public transport in London.When you receive your Freedom Passyou will get full details on how touse it.

Who is eligible?People with disabilities, such as a physicalimpairment or learning difficulty, which has asubstantial and long term adverse effect on theirability to carry out normal day-to-day activities.

This will include the following:

1. Blind and partially sighted

2. Profoundly or severely deaf

3. Without speech

4. Having a disability, or has suffered an injury,which has a substantial long term adverseeffect on the ability to walk.

5. Does not have arms or has long term loss ofthe use of both arms.


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Part A Personal details compulsory

This section must be completed by all applicants.

Title (Mr/Mrs/Miss/Ms/Other): ...............................

Date of birth: ...........................................................

Surname: ................................................................

First name(s): .........................................................

Address: ..................................................................

.................................................................................

.................................................................................

Post code: ..............................................................

Telephone no: ..........................................................

Doctors name:........................................................

Doctors address: ...................................................

.................................................................................

.................................................................................

Doctors telephone no: ............................................

Ethnic group classifcation- optionalThe purpose of this form is to generate statisticsthat enable us to deliver services effectively andfairly. Though this section is optional, it wouldbe helpful if you took the time to fill it in.

(a) White

British

Irish

Any other (Whitebackground)

please write

....................................

(b) Chinese or otherethnic group

Chinese

Any otherplease write

....................................

(c) Black or BlackBritish

Caribbean

African

Any other (Blackbackground)

please write

....................................

(d) Mixed

White and BlackCaribbean

White and BlackAfrican

White and Asian

Any other (mixedbackground)please write

....................................(e) Asian or AsianBritish

Indian

Pakistani

Bangladeshi

Any other (Asianbackground)please write

....................................

Part B Main eligibility criteria compulsory

This section must be completed by all applicants.Please delete as appropriate.

1. Blind or partially sighted

1.1. Are you blind or partially sighted? YES NO

If YES please specify the borough in whichyou are registered:

........................................... and go to Part D.

2. Profoundly or severely deaf

2.1. Has an aural specialist assessed you asprofoundly (70-95 dBHL) or severely (95+dBHL) deaf in both ears?

YES NOIf YES please enclose an audiologicalreport, and go to Part D.

3. Physical disability

3.1. Have you been awarded a Mobility Allowanceor the Higher Rate o the Mobility componentof the Disability Living Allowance for atleast 12 months?

YES NO

If YES please provide a copy of the officialletter confirming your name/address, thedate of your award, and how your allowanceis made up, and go to Part D.

OR

3.2. Have you been awarded a War PensionersMobility Supplement for at least 12 months?

YES NO

If YES please provide a copy of the officialletter confirming the date of your award, ora copy of the pages in your allowance bookdetailing your name/address and how yourallowance is made up, and go to Part D.

OR if you receive neither of the abovebenefits:

3.3. Do you have a disability, or have you sufferedan injury, which has a substantial andlong-term adverse effect on your ability towalk?

YES NO

If YES please go to Part C.


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4. Without speech

4.1. Are you unable to communicate orally?

YES NO

If YES please enclose medical evidence,and go to Part D.

5. Loss of arms or long-term loss of the

use of both arms

5.1. Do you not have arms or have long-termloss of the use of both arms?

YES NO

If YES please enclose medical evidence,and go to Part D.

6. Learning disability

6.1. Do you have a learning disability, that is, astate of arrested or incomplete development

of mind which includes significant impairmentof intelligence and social functioning, whichstarted before adulthood?

YES NO

If YES, but you are not registered with yourlocal authority (Social Services), pleaseprovide medical evidence, and go to Part D.

7. Conditions which would prevent you

from obtaining a driving licence

7.1. Have you been refused a driving license (notincluding refusal due to persistent misuseof drugs or alcohol)?

YES NO

If YES, please send current evidence of thereason, issued by the DVLA, and go to Part D.

OR

7.2. Do you suffer from (please circle):

a) epilepsy

b) severe mental disorder (severe mental

illness)c) sudden fainting attacks

d) inability to read a registration plate at20.5 metres even with the help of glasses

e) other disability which is likely to causethe driving of vehicles to be a source ofdanger to the public. Please specify:

.................................................................

.................................................................

.................................................................

.................................................................

.................................................................

.................................................................

.................................................................

.................................................................

.................................................................

.................................................................

If you suffer from any of the conditions froma) to e), please enclose medical evidence,which state that the above conditions wouldimpair potential driving, and go to Part C.

8. Mental health

8.1. Do you have a severe mental health problemand is attending at least two activities a weekthat have been arranged by the CommunityMental Health Team (CMHT)?

YES NO

If YES, please enclose medical evidence ofyour mental health problem, and go to Part D.

Part C Eligibility assessmentFor applicants who have answered NO to allquestions in Part B, or answered YES to question3.3. Or 7.2 in Part B.

You may be asked to attend an interview in orderto assess your eligibility further.

1. Please describe your illness or disability,giving as much detail as possible (continueon separate sheet if necessary):

2. How long have you suffered from thedisability/ illness?

............. years ............. months

3. For how long do you expect your disability/illness to continue?

............. years ............. months


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Published by the London Borough of Hillingdon August 2010

10563

Part D Compulsory

DeclarationThis section must be completed by all applicants.

Please read and sign the following:

I declare that to the best o my knowledge all the

statements I have made on this orm are trueand I agree to the London Borough o Hillingdoncontacting my GP/Health proessional i necessaryor the purpose o obtaining inormation insupport o my application.

I am permanently resident in the London Borougho Hillingdon and accept the conditions o uselisted overlea. I understand that the provision oany alse inormation as part o this applicationmay render me liable to prosecution. I understandthat inormation about me may be kept on computer

in accordance with the Data Protection Act 1984.

Signed: ....................................................................

Date: ........................................................................

Please send your completed application and anyaccompanying documentation to:

Disabled Persons Freedom Pass TeamHillingdon Social Care Direct

London borough o Hillingdon2W/08 Civic CentreHigh StreetUxbridgeMiddlesexUB8 1UW

4. Do you regularly use a walking aid or awheelchair?

YES NO

If YES, please state the type of aid(s) youuse: .................................................................

........................................................................

........................................................................

........................................................................

........................................................................

How often do you use it/them: .......................

........................................................................

........................................................................

5. How far can you walk on flat ground beforeyou feel breathless, pain or severe discomfortand need to rest?

............. metres/yards (delete as appropriate)

6. Roughly how many minutes does it take youto walk this far? ..........

7. Please give details of how your day to dayactivities are affected by your disability/illness.

.......................................................................

.......................................................................

.......................................................................

.......................................................................

.......................................................................

Please delete as appropriate:

I agree to my GP/hospitalconsultant being consulted. YES NO

I have a named worker inSocial Services and I agree tothem being contacted in

relation to my application. YES NO

Their name(s): .........................................................

.................................................................................

.................................................................................

freedom pass application form.pdf

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