Whizz Kidz Mobility Equipment Application Form

Whizz Kidz Mobility Equipment Application Form
Thank you for completing our General Application Form.

To apply for equipment, you now need to complete the Mobility Equipment Application Form. We cannot proceed with equipment applications until this is completed.

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Whizz Kidz Mobility Equipment Application From
In order to match the information on this form with your initial application to us, please tell us:
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Whizz Kidz provides a range of mobility equipment (including wheelchairs, trikes, buggies, and sports wheelchairs) for children and young people up to the age of 18 who have a physical disability and need a wheelchair for everyday activities.

It is essential that you complete all sections of this form as we need this information to process your application.

Before you complete this form, please check our eligibility criteria:

Eligibility criteria

Your child has a physical disability and requires a wheelchair for everyday activities and participation in day-to-day life.

Your child is under 18 years old when Whizz Kidz receives your application.

If you are applying for a wheelchair/buggy you have contacted your local NHS Wheelchair Service first to determine if they will supply the equipment for your child, or if they will offer you a Personal Wheelchair Budget to work jointly with Whizz Kidz. You will need to tell us why they are not able to supply the equipment your child requires.

Your child has not received mobility equipment from Whizz Kidz within the last two years.

If you are applying for a piece of recreational equipment (for example a trike or sports chair) we will only fund up to a maximum of £3300. If the equipment cost is over £3300 you will need to secure other sources of funding, for example with the help of your family, through another charity or through fundraising. Please note: WK are unable to fund Powered Wheelchairs for recreational purposes, all terrain or sit to stand eg. football chairs.

Please also read the terms and conditions online at http://www.whizz-kidz.org.uk/terms You must sign to confirm you understand these at the bottom of this form.
What equipment are you applying for?*

Manual wheelchairPowered wheelchairAdd on power for a manual wheelchairManual wheelchair plus add on powerOther (ie riser)
What mobility equipment do you currently have, make / model of chair? Please include seating.
(for example, Action 3 Junior with flat cushion and a Jay back)
If applying for add-on power for a manual wheelchair please confirm you have agreement from your local wheelchair service for this to be fitted to your NHS wheelchair
I confirm that I have agreement from my local wheelchair service for this to be fitted to your / my child’s NHS chair*

YesNoN/A

Your child’s measurements
It is essential that we have your child’s current measurements to determine the right mobility equipment for your child. Please ask someone to help you if necessary. Your child’s measurements are best taken with your child sitting as upright as possible on a hard chair, such as a dining chair, or in your child’s wheelchair. You can also find a video demonstrating how to take these measurements here.
What is your child's current weight?*
Please indicate kilograms
What is your child's current height?*
Please indicate in cm
Please provide the following measurements (please indicate in cm):
A = Hip width*
Please indicate in cm
B = Seat depth*
Please indicate in cm
C = Lower leg length*
Please indicate in cm
D = Shoulder height*
Please indicate in cm
E = Top of head*
Please indicate in cm
Inside leg length (for tricycles only)
Please indicate in cm

Your local wheelchair service
Name and address of your child’s local Wheelchair service*
If you are applying for a wheelchair or buggy, have you approached your child’s local service and been informed that the mobility equipment that you require is not available?*

YesNoN/A (trike and specialist sports wheelchair application only)
If yes or no please specify more information:
Local therapist / professional who knows your child well

Therapist details
Title
Name*

First NameLast Name
Occupation*
Contact days*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Work email*
example@example.com
Work telephone*
Mobile
Is your local therapist/professional named above in agreement with this application?*

YesNo
Please provide any relevant details:

More about your child
What is life like for your child without the right equipment?*
Think about how your child gets around at school, at home and when they’re with their friends
What difference will the new equipment make to your child’s life and your child’s family life? *
Think about what your child would be able to do that they can't do now

Contact Details of Parent/Guardian completing the application
Name*

First NameLast Name
Relationship to young person*
Phone number*
Email*
example@example.com
Declaration
I declare that the information is up-to-date and correct at the time of submitting this form, that I have read and understand Whizz Kidz’s terms and conditions, and that I will inform Whizz Kidz if, at any time during my application, any of the above information changes.
Signed*

Clear
Name*

First NameLast Name
Today's date*

DayMonthYear
Date
Whizz Kidz partners with JotForm to gather and process the information you give in this online form. To read JotForm's privacy policy go to www.jotform.com/privacy/

Whizz Kidz promise to keep your information safe. To read Whizz-Kidz's privacy policy go to www.whizz-kidz.org.uk/privacy
Should be Empty:

Whizz Kidz Mobility Equipment Application Form

Whizz Kidz Mobility Equipment Application From

Your child’s measurements

Your local wheelchair service

Local therapist / professional who knows your child well

Information about you as parent / guardian of your child

Your home

Transport requirements

More about your child

Contact Details of Parent/Guardian completing the application

Declaration