The survey will take approximately 4 minutes to complete.

This application form is to request a dedicated and reserved disabled bay (free of charge) in the Milehouse Park and Ride carpark for the entire 2021/22 season.

There are only a limited amount of spaces available, however, there will be a small number of "on the day" spaces on a first come, first served basis for those who are not awarded a season long parking pass.

Please note that any data and information supplied here will be protected and remain confidential. It will only be used for the purposes of applying for a means-tested disabled parking bay and will not be shared with any third parties. Successful applications, will be kept securely on file until the end of the 2021/22 season, thereafter the application form will be reset and new applications will be required. We will process the following information; a first and last name, an email address, vehicle information, and details of your entitlement to a parking space.

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* 1. What is your first name?

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* 2. What is your surname?

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* 3. What is your email address? (we will contact you about your application via this address)

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* 4. What is your address?

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* 5. Please indicate what type of Ticket Holder you are

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* 6. If applicable - what is your membership number?

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* 7. When travelling to Home Park which of the following applies?

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* 8. How do you access your vehicle?

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* 9. What is the make and model of your vehicle e.g. Peugeot Rifter Horizon / Ford Connect etc.

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* 10. What is the registration number of your vehicle?

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* 11. Are you in receipt of any of the following?

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* 12. To help us fully understand your access requirements, please can you supply a short summary of your circumstances, any health conditions we should be aware of and/or equipment you use and will bring to the stadium e.g. mobility scooter user, wheelchair user, ambulant with use of walking sticks/frame.

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* 13. If you are a wheelchair user, is your chair one of the following:

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