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Medical and Health Information
The following requirements are essential for your safety:
· The recommended maximum weight to operate the Breeze 4 is 25 stone.
· You should be able to read a vehicle number plate from a distance of 6 metres and have no significant visual impairment that would prevent you from reading safety signs, avoiding obstacles or other hazards.
· You should have sufficient upper body strength, upper limb mobility and hand dexterity to grip both handlebar grips securely and operate the twist grip.
You should consult your doctor before using the mobility scooter if:
· You have a medical condition that causes / could cause seizures or convulsions; or that affects / could affect your memory, level of consciousness or alertness, balance, mood, or anxiety levels
· You have a history of back problems or spinal conditions
Learning difficulties or developmental conditions:
· Mobility scooter users must have sufficient learning abilities to understand information presented by the instructor, be able to operate and safely control the Breeze 4, identify and avoid hazards, and to react to changes in the surrounding environment. If this is not possible, the carers joystick must be used.
Terms and Conditions of Use
· I understand I am responsible for my own safety, that I must use the Breeze 4 as instructed by the Access the Dales Hub Coordinator and with regard for the safety of other visitors.
· I understand that I can only use the Breeze 4 on recommended routes that have been safety audited and explained to me by the Access the Dales Hub Coordinator at the hire location. If I choose to take the mobility scooter on any other routes or areas, I understand this may affect my safety and do this entirely at my own risk.
· I confirm I have received and read the potential hazards for the approved routes to note potential hazards the Access the Dales Hub Coordinator brings to my attention and understand that the route conditions may change depending on the weather. I understand that I will need to be accompanied by a non-disabled person at some sites
· If using the mobility scooter unaccompanied, I will carry a working mobile phone and site emergency telephone number, and follow any other safety procedures given to me by site staff
· I am 14 years of age or older.
· I am under 14 years old and I will always be accompanied by a parent, guardian, personal assistant or carerwhen using Breeze 4.
· I confirm I have received and read the potential hazards for the approved routes Access the Dales provides third party insurance and that this insurance is only valid if I abide strictly to the Terms & Conditions of use.
· In the event I cause accidental damage or injury to third party property and need to make an insurance claim but can claim under another policy, I understand Access the Dales will only pay a share of the claim and that I must supply Access the Dales with the name and policy number of my insurance company.
· I agree not to use the mobility scooter when under the influence of alcohol or drugs, or medication which could affect my ability to safely operate the scooter.
· I agree not to do anything to the mobility scooter.
· I will not allow anyone else to use the mobility scooter, carry passengers or animals, or be in control of a pet on a lead (registered Assistance Dogs permitted)
· I agree to notify staff of any incident, accident, damage or operational difficulty involving the mobility scooter and complete a statement detailing the circumstances.
· I will return the mobility scooter within the agreed time and understand that failure to do so will initiate emergency/recovery procedures.
· I agree to leave photo ID or car keys for security, which will be returned to me when I return the mobility scooter in the same condition as when it was issued.
· I agree not to leave the mobility scooter unattended, unless I have removed the key and kept it with me, and it is not causing an obstruction.
· I agree to pay the full cost of any necessary repairs resulting from misuse of the Breeze 4.
Hirer’s Full Name : ………………………………………………………………….………..
Hirer’s Signature :…....................................................................................................
Name of parent/guardian/carer if under 14 : ...........................................................
Parent/Guardian/Carer Signature : ..........................................................................
Date : ...................................................................
Address: …..................................................................................................................
….................................................................................................................................
Telephone : ...............................................................................................................
Email : .......................................................................................................................
Access the Dales
Debbie North 3 Birkby Cottages
Northallerton
DL7 0EG
t: 07715-964621 e: accessthedales@gmail.com www.access-the-dales.com
Access the Dales Hire Hub – The Lister Arms
MALHAM, SKIPTON, BD23 4DB – CALL 01729 830444
Accessthe Dales is a registered charity. No 11999349934