Petone Esplanade Accessible Change Room

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Please select why you need to use this facility to help us with planning and facility management

Require Hoist for TransfersRequire Extra assistance in the bathroomOther (Please specify below)

Specify Other Here

Privacy – Personal data collected in this form is confidential and is collected for administration of the facility. It will not be shared.

I have read and understand the following:
I need to supply my own sling if using the ceiling hoist.
That myself/my whānau/carers are responsible for taking care in the facility and reviewing how to effectively use the equipment provided.
I agree to leave the facility in a clean state ready for the next user.
I will wipe down surfaces and dispose of rubbish in the bins provided. *