Changing Places Toilet Application Form

User's Info

First name

Last name

Address

Date of Birth

Phone

Email

Weight For The Hoist

Disability / Impairment

Name

Address

Phone

Email

By signing this, you are agreeing that:

correct details have been given for access to the Changing Places Toilet to be provided.

the disabled person and their carer(s) have been advised to carry a mobile phone when using the Changing Places Toilet.

the disabled person’s maximum permitted weight for the tracking hoist of 200 kgs or 32 stone.

the disabled person and their carer(s) will ensure that the access card is kept secure and not shared with anyone else.

the disabled person and their carer(s) will update the Whitlingham Charitable Trust if any of this information changes.

the disabled person and their carer(s) accept that this information will be held in paper files or on a computer database for the purposes of processing this application, records maintenance and the collection and analysis of statistical information by Whitlingham Charitable Trust.
the disabled person and their carer(s) will use the equipment provided by Whitlingham Charitable Trust in accordance with the manufacturer’s instructions as Whitlingham Charitable Trust will accept no liability for any damage to property or injury to persons arising from a failure to adhere to such instructions when operating the equipment.

This can be paid in cash, or as a donation through our Whitlingham Country Park charities aid foundation page https://cafdonate.cafonline.org/16419#!/DonationDetails

I agree