End of Loan Form

Please do not continue to use your Wizzybug after the loan end date without agreement from our Clinical Team.

If you wish to extend the loan, an End of Loan Extension Application is required. We must ensure that your child is still well supported and fits within the Wizzybug. If your child is too large for the Wizzybug, this can lead to a number of risk factors such as:

Marking the child's skin that could lead to skin breakdown.
Poor posture that could lead to further health issues.
Age-appropriateness of the chair for your child.
If your child's health needs have changed, the Wizzybug may no longer offer appropriate support.

Record ID(Required)

This field is populated from the link provided and cannot be edited.

Child who will be using wizzybug

First Name(Required)

Last Name(Required)

Parent / Guardian

First Name(Required)

Last Name(Required)

Email Address(Required)

Please confirm your address

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Extension or return

Do you wish to extend your Wizzybug loan?(Required)

Please provide a reason for not extending(Required)

What mobility is your child now using?(Required)

Please provide some comments around your child's time using Wizzybug(Required)

Please select your preferred method of Wizzybug return. Please note we offer a free of charge courier collection service(Required)

Deposit

If you paid a deposit of £200 for the Wizzybug Loan Scheme before the 1st March 2022, please indicate whether you would like Designability to return your deposit via bank transfer, or whether you would prefer that we retain this to support our work in allowing more disabled people to live with dignity.

Please indicate whether you would prefer to have the deposit refunded, or to donate some/all of the deposit to Designability.

If you opt for a partial or full refund, this will be sent via bank transfer. Please note that payments can take up to 2 weeks to reach your account.(Required)

Refund full deposit amount (£200)

Donate some/all of the deposit to Designability

N/A - I did not pay a £200 deposit

Deposit Return Amount (£)(Required)

Donation Amount (£)(Required)

Bank details for deposit return

Name on Account(Required)

Sort Code(Required)

Account Number(Required)

Gift aid declaration

Boost your donation by 25p of Gift Aid for every £1 you donate at no extra cost to you!

Gift Aid is reclaimed by Designability from the tax you pay for the current tax year.

We require your address to identify you as a current UK taxpayer.

I want to Gift Aid my donation to Designability(Required)

Yes

No

I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations, it is my responsibility to pay any difference.

First Name(Required)

Last Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date(Required)

About the child

Thank you for letting us know that you are requesting a Wizzybug loan extension. A loan extension cannot be agreed without the completion of this form.

It is important that you do not continue to use your Wizzybug after the loan end date without agreement from our Clinical Team.

To extend the loan period of your Wizzybug we need to ensure that your child is still well supported and fits within the Wizzybug. If your child is too large for the Wizzybug this can lead to a number of risk factors:

Marking the child's skin that could lead to skin breakdown.
A poor posture that could lead to further health issues.
Age-appropriateness of the chair for your child.
If your child's health needs have changed during the loan period, the Wizzybug may no longer offer the appropriate form of support.

Please refer to the User Requirements and How To Measure Your Child documents before completing this section.

Body Measurements (in Sitting)

Please complete the measurements, referring to the image above if needed.

A: Hip width (at widest point in sitting)(Required)

Please enter a number from 0 to 24.5.

0 - 24.5 cm

B: Back of hips to back of knee (seat depth)(Required)

Please enter a number from 18 to 28.

18 - 28 cm

C: Seat to top of shoulder (back height)(Required)

Please enter a number from 26 to 38.

26 - 38 cm

D: Heel to back of knee (lower leg length)(Required)

Please enter a number from 18 to 30.

18 - 30 cm

E: Weight(Required)

Please enter a number from 0 to 20.

0 - 20 kg

Please inform us of any change to your child's conditional or postural needs(Required)

To help us understand if any adjustments are needed to your child's Wizzybug, please can you upload two photos of your child sitting in their Wizzybug: One photo from directly in front and one photo from the side.

Photo from the front

Accepted file types: jpg, jpeg, png, webp, gif, Max. file size: 2 MB.

Photo from the side

Accepted file types: jpg, jpeg, png, webp, gif, Max. file size: 2 MB.

Please confirm the Wizzybug's current seat depth setting below - these settings are colour coded slots from Orange (furthest forward) to Yellow (furthest back).

Seat Depth Colour Setting

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End of Loan Form

End of Loan Form

End of loan form

Child who will be using wizzybug

Parent / Guardian

Please confirm your address

Extension or return

Deposit

Bank details for deposit return

Gift aid declaration

About the child

Body Measurements (in Sitting)