Shopmobility service registration

The information on this form will be retained by the Shopmobility service of North Lincolnshire Council and is purely the membership application and assessment of the applicants ability to use a powered mobility vehicle. This information will not be passed to any other person and/or organisation.

Please note: This is only a registration form and all applicants must attend the Shopmobility Centre for an assessment before they are allowed to use the equipment. Assessments are carried out by appointment between Monday and Thursday. No one is allowed out for the first time on a Friday or Saturday (Scunthorpe Market days) as the town centre is usually busy. If you wish to use the scooters at Ashby you must be first assessed at the Scunthorpe centre.

Name

Title *
If other, please specify
First name(s) *
Surname *

Address

If the address is within North Lincolnshire, enter the postcode in the box below and then select "find address". If the address is outside of North Lincolnshire, or your address is NOT SHOWN in the list or is incorrect, you will need to enter the address in the boxes provided below.

Postcode *


Prefix e.g. first floor flat
House number/name *
Street *
Town/village
County
Country

Contact details

Telephone number *
Mobile telephone number

Email address

Application details

Has the applicant used a powered mobility vehicle before?

Yes

Applicants height

Centimetres

Applicants weight

Stone and pounds

Is the applicant right or left handed

For vehicle controls

Is the applicant right or left handed

Right handed

Left handed

Is the applicant able to get into and out of the mobility vehicle without assistance?

Yes

What is the general nature of the applicant's disability?

How far is the applicant able to walk with and without walking aids?

Is the applicant's eyesight adequate to operate the vehicle safely?

Yes

Is the applicant's hearing adequate to operate the vehicle?

Yes

Does the applicant suffer from general or specific fatigue?

Yes

If Yes, please state extent

Please note: Before you can use one of our scooters you must attend an assessment session at the Shopmobility Centre in Scunthorpe. The assessments are only carried out by appointment from Monday to Thursday each week. Appointments can be made in person at the Shopmobility Centre or by calling 01724 297418.

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