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