Please read these notes carefully as they will assist you in completing
your Leisure Mobility Application Form.
HOW WE USE THE INFORMATION YOU GIVE US
The information you provide will be treated confidentially and will only be shared
with organisations working with us to deliver the Leisure Mobility service. Please be
assured that only relevant information will be shared.
The application process involves a short assessment and training session. Your
personal details (name, address and contact number) may be shared with a
nominated third party who will carry out your training and assessment for us. It may
also be necessary to pass on relevant medical information to them if a medical
condition or disability may affect your assessment and training.
When you become a member of the scheme your details will be placed on a
database that can be accessed by HCT Group and Shopmobility Wood Green. HCT
Group provide the mobile Leisure Mobility service and Shopmobility provide PMV
hire at Wood Green. As a member, you are entitled to use both services.
In some situations, your contact details may also be sent to other relevant parties in
relation to Leisure Mobility. For example, there may be companies working with us
on rare occasions to undertake breakdown and recovery where necessary. We will
not share your personal information if it is not relevant to your application. If,
however, you do not wish your relevant details to be passed on, please contact us
to discuss your concerns.
SECTION A – PERSONAL DETAILS
All applicants must complete this section and provide proof of their permanent
address. This can be a photocopy of one of the following documents:
Your current tenancy agreement
Letter from the Department for Work and Pensions or Her Majesty’s
Revenue and Customs*
Current Council Tax bill or letter from that Department
Current Television Licence or Full British Driving Licence
Alternatively you can provide an original of the following documents:
A recent electric, gas, telephone or water bill*
Bank or Building Society statement*
All proofs must bear your name and address. The documents marked * must have
been issued within the last 3 months. Failure to provide proof of address will result
in a delay in processing your application.
SECTION B – MOBILITY DETAILS
All Applicants should complete this section, giving as much information as possible.
Part 1 Please tick the boxes which best describe your situation. Give as much
detail as possible when listing how your mobility is restricted and provide
details of any medication you may be taking.
Part 2 Please indicate whether you have any hearing, speech or other
Part 3 Please tell us about your mobility difficulties in relation to how far you
can walk or the length of time you can walk. If you are unable to walk
you need only complete questions c) and d).
SECTION C – OTHER DETAILS, DISCLAIMER AND DECLARATION
Please provide any other information that you feel is important that you have not
provided anywhere else in the form. You can put additional information on a
separate sheet if you require.
SECTION D – CHECKLIST FOR RETURNING YOUR APPLICATION
ALL applicants should sign and date the form and return it with the supporting
EQUAL OPPORTUNITIES MONITORING FORM
By filling in this section you will help us to ensure that Leisure Mobility is widely
used by all members of the community regardless of age (16 years plus), gender,
ethnic background, religion or sexual orientation. Please remember to complete this
WHAT WILL HAPPEN NEXT?
On receipt of your application, proof of address, and membership fees (see
overleaf), we will carry out a brief assessment and training session to establish
what PMV you can use, to ensure you are comfortable and to identify any additional
needs and requirements you may have. On successful completion of your training
and assessment, you will be informed of your membership status. For further
information please contact a member of the Leisure Mobility team.
Annual membership to the Leisure Mobility scheme runs from 1st April to 31st
The membership fee is £12.00 for a whole year but works on a pro-rata basis. This
means if you join the scheme during the autumn for example, you will only pay a
Below is a table showing the membership fees payable in relation to when you join
Month you are joining Membership fee to be paid
Please make cheques payable to Wood Green Shopmobility and avoid sending
any cash through the post as it is unsafe.
If you would like to pay your membership fees in cash as opposed to by cheque,
please take your completed application along to Wood Green Shopmobility or the
Leisure Mobility vehicle.
Leisure Mobility Telephone: 020 7275 2444
Transport Coordination Centre email: firstname.lastname@example.org
Ash Grove Depot Website: www.hctgroup.org
London E8 4RH