Register Now

Register now

Simply fill in the registration form below and go to the ShopMobility unit to countersign the registration agreement.

Or you can download the registration form, print it, fill it out and go to the ShopMobility unit to countersign the registration agreement.

As part of the registration, two forms of identification are required which should show name and current address, such as a utility bill, passport and/or driving licence.

Parking

In the Ealing Broadway Shopping Centre multi-storey car park. There are disabled parking bays on the first floor. The car park can be reached from either Grove Road, via St Mary’s Road (opposite Ealing Green), or Windsor Road, via Ealing Common.

Charges

Please contact the ShopMobility office for further details.

To book

Please phone 020 8579 1724 or 020 8840 6977 to book your session.

For more information

Please contact Katie Peploe, the manager at Ealing ShopMobility, on the above telephone numbers or email:shop.mobility@ecil.org

Registration Form

If you use this online registration form, we will contact you, on receipt of this form. You will be required to visit the ShopMobility unit in the Ealing Broadway Shopping Centre car park in order to countersign and complete your registration.

Personal Details

Please enter as DD/MM/YYYY. For example for 5th September 1968 enter 05/09/1968.

Details of Carer / Next of Kin (as applicable)
Additional details
How will you travel to ShopMobility Ealing? (required)

Select all options which are applicable

How good is your eyesight? (required)
Are you able to walk unaided? (required)
Can you transfer to our equipment unaided? (required)
Do you have a Blue Badge? (required)
Do you have your own scooter / powerchair / wheelchair? (required)

In case of Emergency

We need to ask about your impairment

Have you experienced any of the following, in the last 12 months?

Select where appropriate

Data Protection: Information I provide on this form will be used to register my membership with ShopMobility Ealing. My contact details and sensitive data (information pertaining to my health or disability) will be processed in accordance with the Data Protection Act 1998. It will not be passed on to any other parties without my permission.

To be filled in at the ShopMobility unit

This is here for your information and does not need filling in. This will need to be completed at the ShopMobility units in the Arcadia Centre, Ealing.

Staff Use Only

Declaration

I, the undersigned, take FULL RESPONSIBILITY for any wheelchair / scooter / powerchair which is in my care on any occasion that I use the services of ShopMobility Ealing. In particular, I agree that:

  1. The wheelchair / scooter / powerchair (vehicle) will not be left unsecured or be taken away from Ealing Broadway or a 5 mile radius from the ShopMobility units.
  2. The vehicle will be used with due care and attention and returned in the same condition that it was taken out. I will report any damage incurred to the vehicle while in my care.
  3. The equipment borrowed will be returned to ShopMobility Ealing at or before the time agreed.
  4. I use the vehicle at my own risk and all accidents / incidents will be reported to ShopMobility Ealing.
  5. I will be encouraged to demonstrate my ability to operate the vehicle before ShopMobility Ealing will loan it to me and that ShopMobility Ealing reserves the right to refuse the loan of a vehicle.
  6. I am aware that the vehicles have a recommended weight limit and that I may be asked to confirm that I am within the recommended maximum limit for the vehicle proposed each time I visit.
  7. I confirm that as far as I am aware, I do not have any physical, mental or sensory condition which would impair my ability to operate the equipment which is to be lent to me by ShopMobility Ealing and that I have not been advised by my General Practitioner (GP), optician or other qualified assessor of any physical or medical condition which could affect my ability to operate the said equipment.
  8. I understand that failure to abide by the above conditions might invalidate ShopMobility Ealing’s insurance cover.

I have read and understand the conditions set out above and will abide by them.

User's signature

Date

Carer's signature

Date

NOTE:

  1. We need a Parent or Guardian's Signature if the User / Client is under 16 years of age and using a scooter or powerchair.
  2. If a satisfactory declaration cannot be made, then, prior to insurance cover being provided, it will be necessary for us to have a note from your GP, optician or qualified assessor, confirming that in his/ her opinion you are fit to operate the equipment. If you have been advised by your GP, optician or qualified assessor of a physical or medical condition which would render you unfit to operate the equipment, then we regret insurance cover cannot be provided and you will not be able to hire equipment.

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