Scunthorpe Shopmobility Service |
Membership application and assessment form |
| 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. |
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| 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. |
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Address |
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| If you provide a valid email address you will automatically receive a copy of your submitted application form. |
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| Has the applicant used a powered mobility vehicle before? | |
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| Is the applicant right or left handed (for vehicle controls) | |
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| Is the applicant able to get into and out of the mobility vehicle without assistance? | |
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| Is the applicant's eyesight adequate to operate the vehicle safely? | |
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| Is the applicant's hearing adequate to operate the vehicle? | |
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| Does the applicant suffer from general or specific fatigue? | |
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