Access Ability Wisconsin - Outdoors Access 4 All! TM

AAW’s OUTDOOR ALL-TERRAIN WHEELCHAIR (OWC) & TRAILER/CARRIER

OWC CONDITION REPORT (EQUIPMENT CHECK OUT/CHECK IN FORM)

Please refer to the Equipment List to ensure you are checking out the correct equipment with accurate Outdoor Wheelchair(s) OWC # and Trailer # or (Carrier #  ________)           

___ Equipment Checked Out: OWC#___ (Serial #________) Tlr#__ (VIN#_____________________)

 Check Out: User/Client & AAW Representative review the above for any damage to items and list:

  • ________________________________________________________________
  • ________________________________________________________________
  • ________________________________________________________________

I have provided valid driver's license and proof of insurance of the person towing the trailer. I have read the Owner’s Manual and the operation of the Action Trackchair has been explained, demonstrated and I have test driven; any questions I brought up have been answered.   I understand I am to bring the chair and trailer back as I received it, making sure to clean off any debris, sweep out the trailer and bring the OWC back fully charged.  
I have provided: $50 deposit, signed Use and Waiver of Liability Form, signed off on the Detailed Equipment List, and have received one or more surveys(s) for completion upon return:  check all that apply [__] Event (for event coordinator) [__] Individual (for each person using an OWC).
___Yes ___ No 

 ______________________________________          _____________

Customer Signature  _____________________          Date

______________________________________          _____________

AAW Representative _____________________          Date        

AAW Only

Reservation Form

  • Online
  • Mailed
  • Ck-out
  • D.License
  • Insurance
  • Liability Form
  • Detail Equipment Supply List
  • Deposit
  • Ck
  • Cash
  • Mailed
  • PayPal
  • Proper Vehicle
  • Sufficient Clearance
  • Towing
  • Trailer
  • Lights
  • Legs
  • Carrier

Notes:_____________

Check In: User/Client & AAW Representative review equipment checked out listed above for any damaged and dirty items and list:

  • ________________________________________________________________
  • ________________________________________________________________
  • ________________________________________________________________

The chair and trailer have been returned in satisfactory condition, clean and the OWC is fully charged.  You have completed and turned in your survey with DNR CID#, provided a picture, and your $50 deposit has been returned to you.  You have your personal items such as wiring harness adapter, hitch pins/clips, or anything you may have put in the trailer or OWC holders.

 ___ Yes  ___ No: due to dirty  ___ No: due to damaged (see items listed above)

 ______________________________________          _____________

Customer Signature  _____________________          Date

______________________________________          _____________

AAW Representative _____________________          Date        

AAW Only

  • Deposit
  • Returned
  • Donation
  • Notify return needed
  • Destroy ck
  • Survey
  • Returned
  • Will email
  • Pictures
  • Detail Equipment Supplies List (Single/Event)

Notes:___________________________________________________________________

AAW EQUIPMENT LIST

In Madison Metro

OWC # - Serial No.
Location
Trailer # - VIN
Location

Tr#7:- Single trailer to use for event chairs 5NHULT014JA11469

A-Z

OWC#E2-Badger Left Serial#: T02726

A-Z

Tr#E1:- Event -5NHULT219HA112170

A-Z

OWC#E3-Bdgr Narrow Serial#: 3386

A-Z

OSC

Tr# E2:-AAW Events - 5NHULT416KA115628

OSC

OWC#E4 - Pink, Right Hand joystick  Serial#:1478                                                                         OSC

Carrier#1                                               AZ                               

 OWC#9 or E4

Middleton  - (Orchid Heights)

HOST Locations

OWC # - Serial No.
Location
Trailer # - VIN
Location

 OWC#7-BlackSplash Serial#:3384

Tr#7:- Single trailer to use for event chairs 5NHULT014JA11469

OWC#5 - Camo Serial#: T02975

Baraboo

Tr#5:-5NHULT014JA114868

Baraboo

OWC#1-Blk Serial#: 1699

Eagle River, WI 

Tr#1 - Steel -542BA0816FB010813

Eagle River, WI 

OWC#4- BLK/Camo Serial#: T03531

Hayward / FHNB

Tr#4- 5NULT012JA114870

Hayward / FHNB

OWC#6 -CamoLeft Serial#:3385

Hazel Green  / OHEC

Tr#6- 5NHULT014JA114871

Hazel Green
/ OHEC

OWC#8: BLACK Serial#:T03562

IL-Rockton

Tr# 8:- Single - 5NHULT019KA115614
(The NRA LOGO)

IL-Rockton

OWC#2- BLK/Camo Serial#: T02163

La Crosse / NASA

Tr#2 - REEVE -5NHULT013GA110495

La Crosse/ NASA

OWC#-  _____  Serial#: ______

OSC

TR#3 - OSC

OWC#E1 - WTU Serial#: T02727

Tr# 9 - Options for Independent Living

AAW-OWC Condition Report MASTER  (Equipment Check Out/In Form) Rev. February 2020