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Expression Of Interest

First Name

Last Name

Address

Email

Age Group

Under 4 years 4-14 years 14-18 years Adult

Contact Person:

• Myself
• Other

Contact Person Name

Contact Number

Experience Level

• Beginner/Intermediate
• Experienced/Intermediate

Chair Type

• Power
• Manual

ACC Funded

• Yes
• No

MOH Client

• Yes
• No

Skills Group I am mostly able to independently get around in my wheelchair but want to develop more confidence and skills.

Play Group This is a fun play based session for young children, under 4 years old, who are new to using a wheelchair to build confidence getting around. The focus is on exploring moving around rather than a structured skills session.

'Have A Go' Group Continue to need stand-by or hands-on assistance, session for people who use a powered wheelchair
Having difficulty learning to use complicated controls, session for people who use a powered wheelchair