Register as a First Time Client Home 5 Register as a First Time Client Form Thank you for selecting Stryder. We appreciate that you would like to use our services. We have designed the registration process and form to be friendly and straightforward, so that we can warmly welcome you into our Stryder client community. "*" indicates required fields 1PART A2PART B3PART C4PART D5PART E CLIENT DETAILSTitle*Title*MrMrsMsMissOtherGiven Name*Family Name*Date of Birth* DD slash MM slash YYYY AgeGender*Gender*malefemaleotherUsual Address*Suburb*Postcode*Phone*MobileEmail Current Address (if different)Postcode ADDITIONAL INFORMATIONEmergency Contact Name*Phone*Relationship*Doctor’s (GP) NameDoctor’s TelephoneMedicare Number*Country of Birth*Country of BirthAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweEthnicity*Ethnicity*AfghanAlbanianAlgerianAmericanAndorranAngolanAnguillanArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBotswananBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseCitizen of Antigua and BarbudaCitizen of Bosnia and HerzegovinaCitizen of Guinea-BissauCitizen of KiribatiCitizen of SeychellesCitizen of the Dominican RepublicCitizen of VanuatuColombianComoranCongolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanDutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianStatelessSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabweanPreferred Language*Preferred Lanaguage*AfrikaansAlbanianArabicArmenianBasqueBengaliBulgarianCatalanCambodianChinese (Mandarin)CroatianCzechDanishDutchEnglishEstonianFijiFinnishFrenchGeorgianGermanGreekGujaratiHebrewHindiHungarianIcelandicIndonesianIrishItalianJapaneseJavaneseKoreanLatinLatvianLithuanianMacedonianMalayMalayalamMalteseMaoriMarathiMongolianNepaliNorwegianPersianPolishPortuguesePunjabiQuechuaRomanianRussianSamoanSerbianSlovakSlovenianSpanishSwahiliSwedishTamilTatarTeluguThaiTibetanTongaTurkishUkrainianUrduUzbekVietnameseWelshXhosaDo you need an interpreter?* Yes No Are you Aboriginal or Torres Strait Islander?* Yes No Are you on a pension?* Yes No Pension Type* Full pension Part pension Disability Disability DVA DVA Card Option Gold Card Orange Card White Card CARER DETAILS (if applicable)Will a carer travel with you to provide any necessary help?* Yes No Carer’s Given Name*Carer’s Family NameDate of Birth DD slash MM slash YYYY AgeGender*Gender*MaleFemaleOtherCarer’s Address*Postcode*State*State*NSWVICQLDWASANTPhone*MobileClient/Carer Relationship* Family Friend Other RISK ASSESSMENT - HEALTH/DISABILITYDo you have a disability or any health issues that may be relevant to you receiving transport services?* Yes No Disabilities Poor balance Memory Loss Incontinence Bariatric Visual Impairment Intellectual Hearing Physical/Diverse Psychiatric Sensory Speech other - please describeDo you travel with: Guide Dog Oxygen Cylinder other MOBILITYCan you move independently from your home to the vehicle?* Yes No Can you manage alone at your destination?* Yes No How much do you weigh?* Under 100kg 100-130kg 130-150kg Over 150kg Do you require an extension seat belt?* Yes No Do you need to use a mobility aid or other equipment when you travel?* Yes No Walking Stick or Frame Walking Stick? Walking Frame? If walking frame, is it collapsible? Yes No Wheelchair? Wheelchair? Wheelchair Type Manual Electric ModelWeight < 200kgs > 200kgs Collapsible? Yes No Can you transfer independently from your wheelchair to vehicle seat? Yes No YOUR ACCESS TO STRYDER VEHICLES: Our buses have low steps, handrails and wheelchair hoists. (Hoist can be used by people who have difficulty negotiating the steps as well as those in wheelchairs.)Can you manage 2 to 3 steps independently?* Yes No Can you manoeuvre independently in and out of a vehicle?* Yes No Do you require the hoist to access the bus?* Yes No Are you able to access the rear seat of a car, if required?* Yes No Are you confident to travel by a Taxi Service, if necessary?* Yes No Are there any access issues for the vehicle to your home? E.g. No Stopping, no driveway, narrow driveway, main road, apartment block, retirement village?* Yes No Please state ALL access difficulties or appropriate meeting point:How did you find out about us?* Website Friend/Family Health Professional Brochure Facebook Other OtherMy goals for using Stryder are:I’m interested in using the following services: Medical or everyday appointments Social Day Trips Shopping Services Lower North Shore Service Community Access NDIS Transport I am an I am an NDIS Participant On a Home Care Package (HCP) Neither NDIS NumberHCP ProviderI am registered with My Aged Care and have been referred to Stryder (Community Transport, Ryde Hunters Hill) for CHSP subsidised transport. I am registered with My Aged Care and have been referred to Stryder (Community Transport, Ryde Hunters Hill) for CHSP subsidised transport. My AC Number isI understand that by using this service I consent to Stryder accepting your “My Aged Care” referral, and reporting information to funding bodies for planning and statistical purposes. Stryder is a Commonwealth Home Support Program (CHSP) transport provider. I understand that by using this service I consent to Stryder accepting your “My Aged Care” referral, and reporting information to funding bodies for planning and statistical purposes. Stryder is a Commonwealth Home Support Program (CHSP) transport provider. I understand that from time to time photos or videos may be taken during the course of Stryder’s activities and used for promotional purposes. I agree for my image to be used.* I agree I don't agree Name*Date* DD slash MM slash YYYY CAPTCHA
