Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 15I understand that Mobility Trust completes an assessment and funds the purchase of recommended equipment for successful applicants BUT DOES NOT PROVIDE GRANTS for individuals to purchase their own equipment. *I agreeIf I wish to transport my mobility equipment, I understand that Mobility Trust will not fund Boot Scooters or Powered Wheelchairs unless a boot hoist or boot ramp has been installed. *I agreeAfter you submit your Initial Enquiry, it will be reviewed by our team and we will contact you once a decision has been made. Should you be deemed eligible, we will send you a Formal Application to complete which will need to be printed out and returned. Please let us know below whether you have access to a working printer. If not, we will be happy to post a Formal Application to you. the order? I I have access to a printer *--- Select Choice ---YesNoAbout YouTitle *--- Select Choice ---MrMrsMissMsDrProfName *FirstLastDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone *Email *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeNext PageEquipment RequestedWhat Equipment do you need? *--- Select Choice ---Mobility ScooterPowered WheelchairPower PackIf the manual wheelchair you have is from the Local Wheelchair service, do you have permission to use a power pack on the wheelchair? *--- Select Choice ---YesNoWe require written permission from your wheelchair service in order to supply a power pack. Please contact your wheelchair service to discuss this and to request written permission.PreviousNextTo be used for: *--- Select Choice ---Indoor MobilityOutdoor MobilityBothPreviousNextHave you been referred to your Local Wheelchair Service for a Powered Wheelchair? *--- Select Choice ---YesNoDid the Local Wheelchair Service provide you with equipment? *--- Select Choice ---YesNoPlease tell us what equipment has been provided to you. *--- Select Choice ---Manual WheelchairPowered WheelchairCushionBased on the information provided, we regret to inform you that we are unable to offer you any support. At Mobility Trust, we aim to assist those who have no mobility equipment. Many of the individuals who apply to the charity have been unable to leave their homes for years. You have indicated that you currently have a powered wheelchair from your local wheelchair service. We are therefore unable to provide a second piece of equipment. We are sorry that we have not been able to assist you on this occasion and wish you all the best in your effort to obtain a further wheelchair.PreviousNextAre you happy to have equipment selected by OT/Supplier trialled with you? *--- Select Choice ---YesNoN.B. It is a condition of supply that all beneficiaries are trialled in appropriate equipment to ensure they are safe and competent to use and control it.Mobility Trust is only able to provide equipment that has been assessed, trialled, and recommended by our Occupational Therapist and/or approved supplier.We are unable to proceed with an application if you are not willing to accept the equipment recommended for you following this process.We are sorry that we have not been able to assist you on this occasion and wish you all the best in your efforts to obtain suitable wheelchair or scooter provision.PreviousNextHow do you currently mobilise indoors? *--- Select Choice ---Walking FrameWalking StickElbow CrutchesHelp from another personManual WheelchairElectric WheelchairFurniture and WallsNo help neededWhere did this come from? *--- Select Choice ---NHS Wheelchair ServiceCharityGiftPrivate PurchaseBased on the information provided, we regret to inform you that we are unable to offer you any support. At Mobility Trust, we aim to assist those who have no mobility equipment. Many of the individuals who apply to the charity have been unable to leave their homes for years. You have indicated that you currently have a powered wheelchair from your local wheelchair service. We are therefore unable to provide a second piece of equipment. We are sorry that we have not been able to assist you on this occasion and wish you all the best in your effort to obtain a further wheelchair.Is this equipment in working order? *--- Select Choice ---YesNoBased on the information provided, we regret to inform you that we are unable to offer you any support. At Mobility Trust, we aim to assist those who have no mobility equipment. Many of the individuals who apply to the charity have been unable to leave their home for years. You have indicated that you currently have a powered wheelchair in working order and we are therefore unable to provide a second piece of equipment.We are sorry that we have not been able to assist you on this occasion and wish you all the best in your effort to obtain a further wheelchair.PreviousNextDLA/PIPDo you receive DLA/PIP *--- Select Choice ---YesNoAt what rate do you receive the mobility component of your DLA/PIP? *--- Select Choice ---HighStandardNot ReceivedDo you use this benefit for a Motability Car on the Government Motability Scheme? *--- Select Choice ---YesNoMobility Trust is only able to provide funding when no statutory funding is available. As you are awarded PIP at the higher rate for Mobility, you can access a Mobility Scooter or Powered Wheelchair on the Motability Scheme. You can contact them on 0300 456 4566. We are sorry that we are unable to help at this time and would like to wish you all the best in your efforts to obtain the mobility equipment that you require.Has your mobility deteriorated since your last assessment? *--- Select Choice ---YesNoPreviousNextARMED FORCES OR MERCHANT NAVY SERVICE HISTORY Have you served in the Armed Forces or Merchant Navy? *--- Select Choice ---YesNoDue to your service time, you will be entitled to support from the Royal British Legion. They are a much larger charity with fewer restrictions on funding, and we are hopeful that they will be able to assist you with the provision of Mobility Equipment. You can contact them on freephone 08088028080 in order to speak to one of their support advisers, or email ILAsupport@britishlegion.org,uk. We are sorry that we are unable to help at this time and would like to wish you all the best in your efforts to obtain the mobility equipment that you require.PreviousNextHas any member of your family served in the Armed Forces or Merchant Navy? *--- Select Choice ---YesNoWhat family member? *--- Select Choice ---Husband/WifeMother/FatherSiblingChildDue to your spouse's service time, you will be entitled to support from the Royal British Legion. They are a much larger charity with fewer restrictions on funding, and we are hopeful that they will be able to assist you with the provision of Mobility Equipment. You can contact them on freephone 08088028080 in order to speak to one of their support advisers, or email ILAsupport@britishlegion.org,uk. We are sorry that we are unable to help at this time and would like to wish you all the best in your efforts to obtain the mobility equipment that you require.PreviousNextSTORAGEWhere do you plan to store your equipment? *--- Select Choice ---Inside HomeShed in GardenGarageOuthouseGardenFriends or NeighboursWe require the storage to be secure and lockable with a power supply. This must be at your own property. The option you have selected does not meet the requirements of the charity and we are therefore unable to support your application. We are sorry that we are unable to help at this time and would like to wish you all the best in your efforts to obtain the mobility equipment you are seeking.PreviousNextWill the storage be lockable? *--- Select Choice ---YesNoWe require the storage to be secure and lockable with a power supply to charge the equipment. The option you have selected does not meet the requirements of the charity and we are therefore unable to support your application. We are sorry that we are unable to help at this time and would like to wish you all the best in your efforts to obtain the mobility equipment you are seeking.PreviousNextDoes the storage have a power supply, professionally installed? (Please note, running an extension lead is not suitable.) *--- Select Choice ---YesNoWe require the storage to be secure and lockable with a correctly installed power supply to charge the equipment. The option you have selected does not meet the requirements of the charity and we are therefore unable to support your application. We are sorry that we are unable to help at this time and would like to wish you all the best in your efforts to obtain the mobility equipment you are seeking.PreviousNextWill the storage have suitable LEVEL access in and out? *--- Select Choice ---YesNoWe require the storage to be secure, have level access and be lockable with a power supply to charge the equipment. The option you have selected does not meet the requirements of the charity and we are therefore unable to support your application. We are sorry that we are unable to help at this time and would like to wish you all the best in your efforts to obtain the mobility equipment you are seeking.PreviousNextPHOTOGRAPHSMobility Trust requires photographs or a video to show that you have suitable storage. The images or video need to clearly show that your storage is lockable, has sufficient space, has a power supply and has level access.Please upload photographs or a video here. Drag & Drop Files, Choose Files to Upload You can upload up to 10 files. Photo Attached *--- Select Choice ---YesNoIf you have been unable to attach a photo to this form please email it to mobility@mobilitytrust.org.ukI confirm that I will send a photo of the storage as requested to mobility@mobilitytrust.org.ukI understand that my enquiry will remain incomplete and will not be reviewed until a photo has been submitted. *--- Select Choice ---YesNoWe are sorry that we are unable to help at this time and would like to wish you all the best in your efforts to obtain the mobility equipment that you require.PreviousNextWe will only use the data submitted in this form to assess whether or not you are eligible for assistance from Mobility Trust. By clicking here, you are confirming that you are happy for us to use your data in this way. *I AgreeSubmit
