Membership

2020 Scooter Membership Application

Becoming a member of Shopmobility Newry is simple and necessary in order to borrow our equipment. Membership is free and easy to sign-up.

READ T&C

Name(required)

Phone(required)

Email(required)

Address; include postcode

Date of birth / / /

What is your Approximate Height?(required)

What is your Approximate weight?(required)

Do Yo wear Glasses?

Yes No

Are you Left or Right Handed?

Right Left

Can you walk unaided?

Yes No

Can you bend your knees?

Yes No

Do you have;

Epilepsy Diabetes Type 1 Blackouts

What is the cause of your mobility problem?

Equipment required:

Powered Scooter Manual Wheelchair Other

I can confirm that the information I have given is true to the best of my knowledge and I do not have any condition which would impair my ability to safely operate equipment provided to me by Shopmobility Newry.

Do you confirm this?;

Yes No

SEND FORM

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Unit 54a Buttercrane Shopping Centre
Buttercrane Quay, Newry
BT35 8HJ

 028 30256062

 Weekends/Out of Hours 028 30263627

 info@shopmobilitynewry.com

Become a Member

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