EASTLEIGH SHOPMOBILITY
REGISTRATION FORM |
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Title |
First name or initial |
Surname |
Customer No. |
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Address (include Post Code): |
OR c/o Address |
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Tel: |
Tel: |
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Proof of Identify: |
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PERSONAL DETAILS
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No [ ]
Manual [ ]
Power chair [ ] Scooter [ ]
I have used Shopmobility at: ..
2.
What is your APPROXIMATE height and weight?
Height: Weight:
3. Are you
right or left handed? 4. How
is your eyesight?
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6.
Can you walk?
If above answer is No, then are you able to
stand to transfer? Yes [
] No [ ]
Do you need help to transfer? Yes [ ] No [ ]
7.
What is your date of birth?
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8.
Contact Name and Number in case of emergency:
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§
I confirm that
as far as I am aware, I do not have any condition which would impair my ability
to safely operate the equipment which is to be hired to me, and I promise to
inform Eastleigh Shopmobility immediately in event that any change in my
condition may affect my ability to safely operate the equipment.
§
I agree to
take all reasonable precautions whilst using the equipment loaned to me.
Conditions of
Hire:
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Do not get on
or off the scooter/wheelchair without removing the key
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If you are
leaving a vehicle unattended outside a shop, remove the key and take it with
you
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Children are
not allowed to ride on vehicles or to drive them
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Do not
overload the vehicle with excess shopping.
Purchases can be left at the shop until you are ready to leave
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Vehicles must
be returned to Shopmobility by 16.15 hours Monday to Friday and 15.45 hours
Saturdays
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Motorised
vehicles are not to be taken outside the shopping town centre area of
Eastleigh.
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Eastleigh
Community Services / Shopmobility are not responsible for any accidents caused
by failure to follow these conditions of hire.
The information you have
provided on this registration form is of a personal and confidential nature.
There may be occasions when this information (in particular your medical
condition), would be helpful to Eastleigh Shopmobility, in order for us to
ensure a safe and comfortable journey.
From time to time, we would also like to contact you with news of the
service provided in Eastleigh.
If you have no objections
to the information on this form being disclosed for these reasons, then please
do not contact us. If you do not want the details on this form used in this
way, then please make a note of this on the registration form. The information will not be disclosed to an
outside agency.
These details will be placed on computer and are subject to the Data
Protection Act, we are required to ask if you object to this.
I have read and understood the above conditions on vehicle use and agree
to abide by them. I also agree to my
details being held on computer at Eastleigh Shopmobility
Signed
.. Date
Training carried out:
Signed
.. Date