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.

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

Prefix e.g. first floor flat.
House name/number
Street
Village/Area e.g. Scawby, Bottesford, etc.
Town
County
Post code Please input your post code using capitals and include a space between the first and second parts e.g. DN17 5TY.

Email address:

If you provide a valid email address you will automatically receive a copy of your submitted application form.

Date of application

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)

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

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