to Registration Form

Membership Form
Membership No.
To use our mobility equipment in West Dunbartonshire you must become a member of Clyde Shopmobility.
To complete the membership process, please provide the information required.
When you collect/use the equipment for the first time, one of our trained staff/volunteer will show you
how to operate it and check that you are able to satisfactorily and safely carry out all the necessary
manoeuvres.
A. Contact Details
Name
Home Number
Address
Mobile Number
Email
Postcode
Emergency Contact Name
Date of birth
Emergency Contact Number
For insurance purposes we require photo identification and address as part of our membership
registration procedures. This could be a driving licence, rent book, utility bill, council tax statement or
some similar official letter addressed to you.
Proof of identity
Yes
□
No
□
Proof of address
Yes
□
No
□
B. Medical Conditions
Good
1. How good is your eyesight?
2. Can you walk?
3. Do you have Epilepsy?
4. Do you have Diabetes?
□
Yes □
Yes □
Yes
□
Okay
□
No □
No □
□
Visually Impaired
□
No
If Yes a letter is required from your doctor
If Yes, is it controlled?
5. Do you have a medical condition that could impair your ability to operate mobility equipment?
Yes
□
No
□
(If yes please give details)
1
Equipment Weight Limit
Small Scooter - 18 Stone
Manual Wheelchair - 17 Stone
Medium/Large Scooter - 25 Stone
Power Wheelchair - 21 Stone
C. Service Questions
1. Do you require the following services?
Sighted Guide
□
Aide/Escort
□
If you only require Sighted Guide service, please go to page 5
□
Rollator □
Yes □
No □
3. Would you like equipment delivered to you at a suitable meeting point?
4. How did you find out about
Internet □
Radio □ Word of Mouth □
Clyde Shopmobility?
Newspaper □
Signage □
Other □
5. How would you prefer to be contacted?
None/Don't contact □
Phone □
Email □
Post □
2. Preferred Equipment
□
Power Wheelchair □
Manual Wheelchair
Mobility Scooter
Data Protection
Information I provided on this will be used to register my membership with Clyde Shopmobility and to regulate my use
of equipment provided. My contact details and sensitive information relating to my health or disability will be processed
in accordance with the Data Protection Act 1998 and not passed to any third parties without my permission.
If you choose not to provide us with the necessary information then it may not be possible for you to become a member
of Clyde Shopmobility. By signing you consent to our processing of any sensitive data in accordance with this notice.
Users Signature
Date
2