Modulo Ausili per la Mobilità Alimentati a Batterie

Powered Mobility Aid information Form

Se stai pensando di viaggiare con il tuo ausilio per la mobilità, ti preghiamo di compilare questo modulo
in stampatello e attaccarlo alla tua sedia a rotelle, scooter, ecc.
If You are planning to travel with Your own mobility aid, please complete this form in capital letters
and attach it to Your wheelchair/scooter.

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Nome e Cognome del cliente | Name of passenger

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Volo/Data | Flight/Date

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Aeroporto di partenza | Station of departure

INFORMAZIONI SUL TUO AUSILIO PER LA MOBILITÀ | MOBILITY AID INFORMATION:

Ausilio Elettrico Manuale

Chair type Power Manual

Tipo di batteria: Gel/Secco (Non-spillabili) wet cell (Spillabili) Batteria al litio

Battery type: Gel/Dry type (non spillable) Wet cell (Spillable) Lithium battery
( Nichel-metal, hydride)

La batteria é rimovibile? SI NO
Is your battery removable? Yes No

Il tuo ausilio è attivato da una chiave? SI NO

Is the mobility aid key operated? Yes No

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Dove hai conservato la chiave? | Location of the key (where you’ve stored the key)

Peso della sedia/scooter: Ibs KG

Chair weight Ibs KG

Dimensioni dell’ausilio | Chair dims ________________________________________________ ________________________________________________ ________________________________________________

Lunghezza | Length Larghezza | Width Altezza | Height

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Posizione del freno | Location of brake release

Ci sono delle parti removibili? SI No (es. Per il collo, le gambe, ecc.)

Are there any removable parts? Yes No (e.g .Head rest/Leg rests)

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Lista delle parti removibili | List all removable parts