Campus Wheelchair Request Form

Phone

This field is for validation purposes and should be left unchanged.

Requestor Information

Name(Required)

First Last

Department(Required)

Position(Required)

Email(Required)

Phone/Extension(Required)

Wheelchair User Information

Name of Individual Requiring Wheelchair(Required)

First Last

Relationship to Brandon University(Required)

Request Details

Date(Required)

Time Required From(Required)

:

Time Required Until(Required)

:

Building/Location Where Wheelchair Will Be Picked Up(Required)

Destination(s)(Required)

Purpose of Use

Purpose of Use(Required)

Medical Appointment
Campus Event
Temporary Mobility Assistance
Injury/Illness
Accessibility Support

Will assistance be provided to transport the wheelchair user?(Required)

Yes
No

If yes, by whom?(Required)

Acknowledgement

Acknowledgement(Required)

Clicking this acknowledges that you agree to the terms below

• The campus wheelchair is intended for temporary mobility assistance only.
• The wheelchair will be returned promptly at the agreed-upon time.
• Any damage, malfunction, or concerns will be reported immediately to Health & Safety.
• The wheelchair user will not be left unattended if they require assistance.
• Brandon University is not providing medical care through the loan of this equipment.

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Brandon University