Walker Mobility Order Form

WAIVER AND ASSUMPTION OF RISK

I client voluntarily sign this Waiver and Assumption of Risk in favor of Walker Medical & Mobility, inconsideration for the opportunity to use the Owner's electric scooters and wheelchairs.

I understand that there are certain risks and dangers associated with the activity and use of the electric scooters and wheelchairs. I fully understand the risks.

I fully assume the risks and I agree to use my best judgement in undertaking these activities and follow all safety instructions.

I waive and release the Owner from any claim for personal injury, property damage, or death that may arise from my use of the electric scooters and wheelchairs.

Order Form

Please complete the form below. Mandatory fields marked*

Step 1: Your Details

Your Name*
How did you hear about us*
Person's Name Holding Hotel Reservation*
Billing Address*
City*
State*
Zip Code*
Country*
Home Phone*
Cell Phone
Your Email Address*

Step 2: Hotel Information

Your Destination City*
Name Of Hotel*
Hotel Address
Hotel City
Hotel Phone Number

Step 3: Please Choose Equipment Needed

Equipment	Rider Size	Price	Quantity Needed (0-100)
Scooters
Standard Scooter	Up to 300lbs.	$30.00/day
Heavy Duty Scooter	Up to 425lbs.	$39.00/day

Wheel Chairs
18 inch	Up to 240lbs.	$30.00 1st day $6.00/each Add. day
20 inch	Up to 280lbs.	$35.00 1st day $6.00/each Add. day
22 inch	Up to 340lbs.	$40.00 1st day $7.00/each Add. day

Step 4: Rider & Delivery Information

Rider's Height*
Riders Weight*
Arrival Date
What Date & Time Will The Equipment Be Needed?*
Time:
What Date & Time Will You Be Finished With The Equipment?* Time:
Other Important Delivery Information

Step 5: Are You A Travel Agent?* Yes No

Travel Agent Details

Agents Name
Agency Name
Agency Address
Agency City
Agency State
Agency Zip Code
Agency Phone
Agency Fax
Travel Agent's Email Address

Step 6: Payment Information

Credit Card Type* Visa Mastercard American Express Discover
Credit Card Number*
Card Holder's Name*
Expiration Date*
Security Code*

Step 7: Final Approval

Click here to review the Rental Agreement & Waiver of Liability
Check box to Agree to Rental Agreement & Waiver of Liability

If you have any questions, call us at 1-888-SCOOTER Monday thru Sunday 7:30am-8pm est.

Travel Agents

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