Concessionary Travel for Disabled People

Transcription

1 Cocessioary Travel for Disabled People A Easy Read Applicatio Form

2 Itroductio This Easy Read booklet explais: who ca apply for a West Midlads Combied Authority Cocessioary Travel Pass, ad how to apply for a pass. Who ca apply? You ca apply for a travel pass if: you have a log term disability, or you expect to be disabled for the ext 12 moths you are over five years old Sadwell, Solihull, Walsall or Wolverhampto. How do I apply? Read the categories o Pages 13 to 18 ad check that oe or more applies to your disability. Fill out the applicatio form o Pages 9 to 22. 2

3 Sed us copies of the documets, please do t sed us origial documets because we wo t be able to sed them back. You will have to pay for postage, photographs or documets from GPs. your ame ad postcode o the back. You could get oe take at a local post office or chemist. Sed us a documet with your ame o it as proof of your address: a bak statemet that is less tha six moths old a bill that is less tha six moths old a doctor or hospital letter that is less tha six moths old Post your applicatio ad documets to WMCA, PO Box 9421, Birmigham, B19 3TR. It ca take us up to 8 weeks to look at your applicatio. 3

4 We may eed to cotact you, so make sure you sed us your phoe umber or address o Page 10 of the applicatio form. If you do ot sed us the correct documets this may hold up your applicatio. If you are uder 18 You will get a pass that you ca use before 9.30am l if you are aged 5 to 15 l if you are aged 16 to 18 ad you are i full time educatio. If your school makes the applicatio, your paret or guardia will eed to sig it. Letters will be set to your home address, ad we may cotact your school if we eed to. 4

5 Need a differet format? If you would like a copy of this documet i a format that suits your eeds such as large prit or audio you ca. Call us o us at customerservices@tfwm.org.uk If you eed to speak to someoe i a differet laguage you ca call us o We will use Laguage Lie to help. About the pass Where ca I use the pass? O local buses aywhere i Eglad. O most buses, trais ad Metro i the Network West Midlads area. Whe ca I use the pass? O buses, trais ad Metro i the Network West Midlads area after 9.30am Modays to Fridays ay time Saturday, Suday ad Bak Holidays. 5

6 O ay local bus i Eglad from 9.30am to 11pm, Moday to Friday ay time Saturday, Suday ad Bak Holidays. AM PM How do I use the pass? O buses place your pass over the reader ad wait for the gree light to show. O trais ad Metro show your pass to coductor whe asked. Travel before 9.30am You ca pay for each jourey. Or you ca get a Pre 9.30am ticket, which will save you moey if you travel a lot i the Network West Midlads area before 9.30am. Your local coucil may be able to help towards the cost of your Pre 9.30am ticket. 6

7 How much does a Pre 9.30am ticket cost? To fid out the most up-to-date cost you ca visit our website etworkwestmidlads.com call us o You ca pay for a Pre 9.30am Ticket by Direct Debit that s a amout that comes out of your bak accout To sig up just use the lik below. etworkwestmidlads.com/directdebit 7

8 Hospital travel If you eed to travel before 9.30am for NHS treatmet, you ca make a claim to reduce the cost of your Pre 9.30am ticket at the place you are treated, such as: a hospital NHS Cetre private cliic. What happes if I lose my pass? to get a ew pass If you lose your pass you will have to pay for a ew oe. If your pass is stole you will ot have to pay. But you will eed get a Crime Referece Number from the police. 8

9 Applicatio Form Checklist I have applied for the right category I have completed all sectios I have used block capital letters I have siged the declaratio I have icluded supportig documets I have used the correct postage Your photo Stick your passport photo to this box usig glue, sticky tape or staples Part 1: About you Your title: Mr Mrs Miss Ms Other Are you: Male? Female? First ame Last ame 9

10 Address Postcode Phoe umber (i case we eed to cotact you) address Date of birth dd mm yyyy How would you like us to cotact you, if we eed to? (Tick all that apply) Letter oly oly Letter ad Large Prit What is your Natioal Isurace umber? 10

11 Do you hold a full drivig licece? No Yes, a full licece Yes, a provisioal licece Have you bee awarded the Disability Livig Allowace or Persoal Idepedece Paymet by the DWP? Yes No If you ticked Yes please sed us l your full award letter with your applicatio l other documets that we eed for the category you are applyig uder. Your award letter must be less tha 12 moths old. DWP ca sed you the details of your award. 11

12 Part 2: Your doctor Your doctor s ame Address Postcode GP Phoe No GP address 12

13 Part 3: Your category The law says you ca apply for a travel pass if you have a disability as described by oe of seve categories listed o Pages 13 to 18 You ca apply for more tha oe category, but you must provide the documets for every category you apply for. Please tick the boxes so that we ca see: l the category you are applyig for ad l the documets you are sedig. Category A I am blid or partially sighted You ca apply if you are blid or partially sighted i both eyes. Please sed us ONE of these documets A registratio card from your local coucil Certificate of Visio Impairmet (a CVI, which used to be called a BD8) 13

14 Category B I am deaf You ca apply if you are very deaf or oly able to hear a little soud. Please sed us ONE of these documets Proof you are registered with your local social services departmet as deaf. Audiogram from a specialist sayig you caot hear very well - 75 to 90 dbhl i both ears. 8 Category C I caot speak You ca apply if you caot speak at all i ay laguage. You caot apply if your speech is slow or difficult to uderstad. Please sed us ONE of these documets A letter from Departmet of Works ad Pesios (DWP) less tha 12 moths old that says you get a Persoal Idepedece Paymet (PIP) with a score of 8 or more i the Commuicatig verbally activity. A medical report that says you do ot have ay speech. 14

15 Category D I have a walkig disability You ca apply if you have a log term disability that meas you caot walk or it is difficult for you to walk. Your impairmet is the same as someoe who gets l high rate mobility compoet of the Disability Livig Allowace (DLA) l Stadard or ehaced rate of the mobility compoet of a PIP. Please sed us ONE of these documets A letter from DWP less tha 12 moths old that says you get the High Rate Mobility Compoet of the DLA. A letter from DWP less tha 12 moths old that says you get a PIP with a score of 8 or more i the Movig aroud activity. A letter from the Service Persoel & Veteras Agecy (SPVA) that says you get a War Pesios Mobility Supplemet (WPMS). A copy of both sides of your Disabled Persos Parkig permit (Blue Badge). This must be oe of the ew style plastic permits. How far ca you walk i metres? l without stoppig, l gettig a lot of pai or l eedig help from aother perso? I ca walk for metres Please ote: You may eed to go to a assessmet cliic to check your walkig ability. 15

16 You ca apply if you caot use both of your arms, ad your disability has a big impact o daily activities such as payig a fare o a bus or trai. Please sed us this documet arms for daily tasks. We use the World Health Orgaisatio (WHO) guidace which says that someoe is learig disabled if all three statemets apply it is difficult to uderstad complex iformatio or lear ew skills it is difficult to live idepedetly Please sed us SOME of these documets A letter from your school about your learig ability. The full statemet of Special Educatioal Needs or Idividual Educatio Pla ad ay reviews. of a residetial care home that says you meet the three statemets 16 Cotiued o page 17

17 A copy of your patiet summary, cofirmig you have bee diagosed with a severe, moderate or mild learig disability. This ca be obtaied from your Doctors surgery. A letter from a medical professioal such as a GP, that says you have a learig disability ad whether it is mild, moderate or severe. A medical professioal does ot have to be your GP. For example, it ca also iclude a CPN, learig disability specialist, Occupatioal Health therapist or a Psychiatrist. because I have a medical coditio You ca apply if you would be refused a drivig licece because of your medical coditio if you are over 16. You caot apply if you have a drivig licece if your medical coditio is due to alcohol or drugs. You may get a pass if you have ONE of these coditios have fits you caot cotrol (this is called epilepsy) have severe metal health issues may suddely fait or black out ay disability that makes it dagerous for you to drive. Cotiued o page 18 17

18 Please sed us ONE or more documets Proof of ay medicie you have take i the last six moths. A medical letter about your epilepsy or seizure. A letter from DVLA, less tha 12 moths old, that says your drivig licece has bee refused or take away. A letter from a medical professioal (a medical professioal does ot have to be your GP. For example, it ca also iclude a CPN, Epilepsy specialist, Occupatioal Health therapist or a Psychiatrist) that says you would ot get a drivig licece if you applied a copy of your patiet summary cofirmig your coditio. This ca be obtaied from your Doctors surgery. you would be dager to yourself or others if you did drive. 18

19 How we will use your data West Midlads Combied Authority ad other agecies eed to have your persoal iformatio to ru the travel scheme. We will follow the law o keepig persoal iformatio. We may share your iformatio with the police or other agecies to protect public moey ad prevet fraud. Medical matters I agree that West Midlads Combied Authority may eed to cotact my GP I agree that iformatio about me will be set assessmet. If you agree please tick this box All the iformatio i this form is true. I uderstad that if I have give ay false iformatio, legal actio may be take agaist me. If you agree please tick this box 19

20 Your sigature (If you are uder 16 your paret or carer must sig) Date: If this form was completed by someoe else please complete the form below: What is their ame? What is their relatioship to you? If this perso works for a school or orgaisatio please write its ame here. Sigature of perso who completed the form Date: 20

21 Ethicity White Eglish Scottish Welsh Irish Ay other White backgroud (please write i the box below) Mixed White ad Black Caribbea White ad Black Africa White ad Asia Ay other Mixed backgroud (please write i the box below) Asia or Asia British Idia Pakistai Bagladeshi Ay other Asia Backgroud (please write i the box below) 21

22 Chiese or Other ethic group Chiese Other (please write i the box below) Black or Black British Caribbea Africa Ay other Caribbea/Africa backgroud (please write i the box below) Post your form ad documets to West Midlads Combied Authority, PO Box 9421, Birmigham, B19 3TR you sed your applicatio to West Midlads Combied Authority. 22

23 Useful iformatio etworkwestmidlads.com For iformatio about buses ad Metro call Travelie Calls to this umber cost 12p per miute plus etwork extras For iformatio about rail call Natioal Rail Equiries Calls to this umber cost 10p per miute plus etwork extras Keep this booklet safe for iformatio about your travel pass ad where you ca use it. 23

24 This Easy Read booklet was writte ad produced by JUN16056