(02) 88 68 1400
mail@communitywheels.org.au

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WHAT WE OFFER
GETTING STARTED
WHAT’S ON
ABOUT US
CONTACT US

WHAT WE OFFER
GETTING STARTED
WHAT’S ON
ABOUT US
CONTACT US

Become a Client

Please fill and submit the form to register as a client with Community Wheels

Check your eligibility

Before you fill this form, please check your eligibility for community transport. We provide subsidised transport for people over 65 years (50 for Aboriginal and Torres Strait Islanders) living in Parramatta & Cumberland LGAs, who are referred through My Aged Care. We also provide subsidised transport services for clients under 65 who are financially or transport disadvantaged-Please call the office to check eligibility. To register with My Aged Care, call 1800 200 422 or visit http://www.myagedcare.gov.au

Personal details of the new client

Title

First name

Last name

Full address with suburb

Post Code

Transport no

AC Number

P.O. Box (Option)

Primary Phone number (do not put spaces between numbers)

Secondary Phone Number

Date of Birth

Country of Birth

Main language spoken

Do you need an interpreter?

Yes No

Are you Aboriginal or Torres Strait Islander?

Yes No Rather not say

Accompaniment

Will a carer or family member accompany you on your trips?

Yes No

Name of person accompanying you

Phone Number of person accompanying you (do not put spaces between numbers)

Medicare, Pension and Other Details

Do you receive a pension or any other government benefit?

Yes No

Pension no.

Medicare no.

Are you on any package?

Yes No

Is the property you live in

Living Situation

Mobility Details

Do you use any kind of mobility aid? (example - walking stick, wheelchair, etc.)

Yes No

Are you able to climb 2-3 steps into a van or bus with handrail support?

Yes No

Please tell us about any mobility issues you may have

Medical Conditions

Do you have any medical conditions we should be aware of (optional)

Emergency Contact Details

Emergency contact name

Emergency Contact Phone Number (do not put spaces between numbers)

Relationship

Referral

How did you hear about us?

Personal details

I AM FILLING OUT THIS FORM FOR SOMEONE ELSE

Date Filled Out

Prepare Name

Preparer Phone Number (do not put spaces between numbers)

Personal details of the new client

Title

First name

Last name

Full address with suburb

Post Code

Transport No

AC Number

P.O. Box (Option)

Primary Phone number (do not put spaces between numbers)

Secondary Phone Number

Date of Birth

Country of Birth

Main language spoken

Do you need an interpreter?

Yes No

Are you Aboriginal or Torres Strait Islander?

Yes No Rather not say

Accompaniment

Will a carer or family member accompany you on your trips?

Yes No

Name of person accompanying you

Phone Number of person accompanying you (do not put spaces between numbers)

Medicare, Pension and Other Details

Do you receive a pension or any other government benefit?

Yes No

Pension no.

Medicare no.

Are you on any package?

Yes No

Is the property you live in

Living Situation

Mobility Details

Do you use any kind of mobility aid? (example - walking stick, wheelchair, etc.)

Yes No

Are you able to climb 2-3 steps into a van or bus with handrail support?

Yes No

Please tell us about any mobility issues you may have

Medical Conditions

Do you have any medical conditions we should be aware of (optional)

Emergency Contact Details

Emergency contact name

Emergency Contact Phone Number (do not put spaces between numbers)

Relationship

Referral

How did you hear about us?

Our vision is to transport and support individuals and communities to participate in a range of activities that will improve their wellbeing and independence.

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Unit 3E, 6 Boundary Road Northmead, NSW, 2152

(02) 8868 1400

mail@communitywheels.org.au

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