Passenger Assistance App Trial - Application to Participate

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1. About You

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1. Your full name *

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2. Your email address *

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3. Please indicate your impairment(s) which is linked to your experience of physical/social barriers: *

Wheelchair/scooter use
Visual impairment
Hearing impairment
Mental health
Mobility impairment
Memory loss
Learning disability
Prefer not to say
Other (please specify):

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4. If you use a powered wheelchair or mobility scooter, we can only carry on our trains and ramps those which are 700mm by 1200mm in size and 300kg in combined passenger and scooter weight. Please confirm your wheelchair or scooter meets this criteria. *

I do not use a wheelchair or scooter
Yes, my wheelchair/scooter does meet the criteria
No, my wheelchair/scooter does not meet the criteria

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5. How often do you use Passenger Assistance services for rail travel? *

At least once a week
2-3 times a month
At least monthly
Several times a year
Around once a year
Less than once a year
I don't normally use assistance

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6. We offer a free travel pass to use when you are doing your journeys for the app trial. It can only be used on West Midlands Railway and London Northwestern Railway trains. Would you like to apply for a free travel pass to use for the trial? *

Yes
No

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7. Please confirm that you have read, understood and agree to the terms of the trial on the website *

Yes
No