Apply for Help

Mobility Trust provides powered wheelchairs and scooters for people who have severe disabilities and who cannot obtain such equipment through other means. We aim to assist as many people in need as we possibly can.

However, before we know whether or not we might be in a position to help you, there are a number of questions we need to ask to ensure that you are eligible for assistance. We would therefore be grateful if you could fill in the form below.

Url

Title *

First Name *

Email *

Last Name *

Phone Number *

Address 1 *

Address 2 *

Town *

Post Code *

Equipment Requested *

Scooter

Powered Wheelchair

To be used for: *

Indoor Mobility

Outdoor Mobility

Both

Are you happy to have equipment selected by OT/Supplier trialled with you? *

Yes

N.B. It is a condition of supply that the beneficiary be trialled in appropriate equipment to ensure they are safe and competent to control it.

LOCAL WHEELCHAIR SERVICE

Have you been referred to your LWS? *

Yes

Have they provided you with any equipment? *

Yes

If your answer above is yes, please tell us what equipment has been provided to you. If your answer above is no, please put N/A. *

How do you currently mobilise indoors? *

DLA/PIP

Do you receive the Higher Rate Mobility component of DLA/PIP? *

Yes

If yes, what do you use it for? If no, please put N/A *

STORAGE

Where do you plan to store your equipment? *

Garage

Shed

Inside Home

Other

If other, please specify or put N/A. *

Will the storage be lockable? *

Yes

Will the storage have a power supply? *

Yes

Will the storage have suitable access in and out? *

Yes

N.B. We will only use the data submitted in this form to assess whether or not you are eligible for assistance from Mobility Trust. By clicking on the Submit button, you are confirming that you are happy for us to use your data in this way.

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