Name(Required)

First Last

Name (joint contracts)

First Last

Only complete this if you are joint tenants

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City Postcode

How would you like us to contact you?

Who will be using the scooter?(Required)

If this is not you, what is their relationship to you?(Required)

Where do you plan to store the mobility scooter?(Required)

If there is a specific store where you live, please note this down. You will be expected to use this.

Make, model and classification of scooter(Required)

Charging type(Required)

E.g. built in or removable battery

Where to you plan to charge your scooter?(Required)

Charging scooters should only be done behind a fire-resistant door and never on a stairwell or any escape route as it is particularly high risk.

Do you have public liability insurance?

Yes

If we agree to your request, you will need to have this in place straight away and provide us with a copy of the insurance certificate.

How will you make sure your scooter is maintained / serviced or PAT tested?(Required)

You must make sure the mobility scooter is in good working order when you get it, that it is serviced and maintained in a safe condition and charging adaptors are PAT tested.

Has an occupational therapist assessed the need for a mobility scooter?(Required)

Yes

Please provide a copy of the occupational therapist's recommendations and their name and contact details.

Name(Required)

First Last

Phone

File

Drop files here or

Max. file size: 64 MB.

Have you decided yourself that a scooter is needed and for what reason?(Required)

This can help us make sure you have the support you need to be safe in your home

Things to consider regarding a mobility scooter

It is your responsibility to keep the scooter serviced and maintained in line with manufacturer’s instructions. You must have insurance that enables you to rectify any damage that you may cause with the scooter, whether to another person or your home/communal areas. Mobility scooters cannot be stored in communal areas (unless a designated scooter storage area is available). Your use and storage of the scooter must not cause a nuisance to others or breach your contract in any other way.

Conditions: I (the owner and user) agree that:

Only the person whom the scooter is for will use it in the home and community/scheme. I will not cause damage to my/our home or communal areas through use or neglect of the mobility scooter. I am liable to pay for any damage caused due to use and/or improper storage of any part of the mobility scooter. Insurance to cover damage to property and third-party injury will be in place when the scooter is purchased. The scooter will be stored appropriately, and I/we agree to follow any specific instructions Hafod give regarding this. The scooter will be charged appropriately, in line with manufacturer’s instructions and any specific instructions Hafod give regarding this. I may be charged for costs Hafod incur, such as scooter charging or testing in designated storage/charging areas. I will ensure it does not cause a nuisance to others or breach any other part of my/our contract responsibilities. I understand that if consent is given but these conditions are not met, consent to keep a scooter may be withdrawn. In consenting to this request, Hafod may require any other reasonable conditions in relation to my/our request. I will update Hafod if I change the scooter and may be asked to make a new request to ensure the details above are kept up to date.

Name (tenant 1)(Required)

Date(Required)

Name (tenant 2)

Date

CAPTCHA

Request for a mobility scooter

Things to consider regarding a mobility scooter

Conditions: I (the owner and user) agree that: