ORCAS ISLAND LIONS CLUB Powered Mobility Equipment Loan Request & Agreement (Electric Wheelchairs and Scooters) This agreement is for the temporary loan of powered mobility equipment. The loan ends when you no longer need the equipment. When the loan ends, you are responsible for returning the equipment in good condition to the Orcas Senior Center. PLEASE PRINT RECIPIENT
CARE GIVER (if any)
Name:
Name
Street:
Street:
City:
Zip:
City:
Tel:
Tel:
email:
email:
Zip:
Please indicate all pertinent physical information concerning the recipient. This is important to properly match the equipment to the individual who will use it. Height _____
Weight ______
Intended Usage: Indoor Y / N
Full use of both hands? Y / N
Outdoor Y / N
Control Joystick Mounting Right or Left? (for wheelchairs only) Able to rise from seated position without armrests? Y/N Equipment Issued Type: ________________________________ Make & Model: _________________________ Lions Serial Number: _____________________
The Mobility Assistance Equipment loan program is a joint project of the Orcas Senior Advisory Committee and the Orcas Island Lions Club. It is operated by Orcas Island Lions Club. We depend on volunteers, contributions of equipment and donations from the public. Anything you can do to help or contribute is appreciated.
1/23/2011
Mobility Equipment Agreement and Conditions THE UNDERSIGNED, hereinafter referred to as the “applicant,” has made an application to the ORCAS ISLAND LIONS CLUB, Eastsound, Washington, hereinafter referred to as the “Club,” to obtain the use of Durable Mobility Equipment, hereinafter referred to as “equipment,” owned by the Club and made available by the Club to Orcas Island residents for use on a temporary basis without charge. The Club, having determined that the applicant meets the qualifications and standards of the Club for use of the equipment, agrees to provide it for the use of the applicant without charge, upon the following terms, agreement and understanding: 1. Ownership of the equipment is in the Club, and upon completion of use and need for the equipment, it shall be returned to the Orcas Senior Center to be made available to others. 2. In the event that the equipment becomes in need of repair or maintenance, the applicant shall promptly notify the Orcas Senior Center of such need by telephoning (360) 376-2677, and shall cease using the equipment until it has been repaired or replaced to avoid possible injury to the applicant or others. 3. In consideration of being able to use the equipment without charge, the applicant does hereby waive and release any and all claims against the Club or the Orcas Senior Center and any of its members or volunteers for any personal injury or property damage suffered by the applicant from any and all causes whatsoever arising out of the equipment. 4. The applicant shall not loan out or allow others to use the equipment, it being understood the same is provided to the applicant personally only.
Care of the Equipment The applicant must always use the equipment in a safe and sensible manner to avoid injury and damage. If the equipment is in need of maintenance or damaged in any way, it must not be used. The applicant must return such equipment to the Orcas Senior Center to be serviced and fixed, or exchanged for comparable equipment that is working properly. Home repairs are not allowed. The applicant MUST: Transport and store the equipment in a dry, enclosed space; Use the equipment only on stable surfaces for which it was designed; Maintain the correct air pressure in the tires; Charge the batteries daily on power scooters and power chairs; Keep the equipment clean and in good condition. The applicant MUST NOT: Use or leave the equipment in the rain or snow; Use the equipment on surfaces that are slippery or unsafe; Overload the equipment with too much weight; Use the equipment if it is in need of repair or maintenance; Leave the equipment unattended in a public place; Make any repairs or modifications to the equipment.
1/23/2011
Replacement of batteries: Battery life is influenced by a number of factors including usage and charging patterns. Depending on the equipment assigned, indications of batteries requiring replacement could be declining performance (more frequent charging required), or a warning indicator on your controller. If you believe the batteries may be failing, please bring the loaned equipment (including the charging unit if separate) to the Senior Center. We will test the batteries and if they require replacement, obtain and install same. The applicant is responsible for the cost of replacement batteries as required.
Questions, Returns, Help: Call the Orcas Senior Center at (360) 376-2677. They will be able to advise you of the Mobility Equipment Center hours and if an urgent need exists, forward your message to the Orcas Lions Club.
I have read the entire loan agreement and conditions, I understand them, and I agree with them. Signature, applicant/responsible party: ___________________ Date:_____________
Checked by Lion: __________________
1/23/2011
