Mid-Cities AMBUCS REQUEST FOR AMTRYKE®

THEREAPEUTIC TRICYCLE APPLICATION

(To be filled out by parent/guardian!)

CHILD’S NAME: ________________________________________________________________________

AGE: _________________________

DATE OF REQUEST ____________________________________________________________________

MAILING ADDRESS: PHONE # ______________________________________________________________________________

CITY/ STATE/ ZIP: County_________________________________

PARENT’S/GUARDIAN NAME: __________________________________________________________

PHONE #_________________________________ Email: _____________________________

ADDRESS _________________________________________________

CITY ST ZIP: ________________________________________________

SECONDARY CONTACT NAME:___________________________________________PHONE: ___________________________

DIAGNOSIS OF CHILD: ____________________________________________________________________________________

TREATING THERAPIST’S NAME:

TITLE/FIELD: ________________________

PHONE: EMAIL: _________________

HOW DID YOU HEAR ABOUT THE AMTRYKE® THERAPEUTIC TRICYCLE? (CHECK ALL THAT APPLY)

THERAPIST WEBSITE AMBUCS™ MEMBER ________*OTHER

*IF OTHER PLEASE SPECIFY WHERE: _________

AMTRYKE® DEMONSTRATION SITE, GIVE NAME/STATE: ______________________________________________________

**IS FINANCIAL ASSISTANCE NEEDED IN OBTAINING THE TRICYCLE? YES _____ NO

*IF YES, HOW MUCH CAN YOU PAY? ______________________________

I AGREE TO “RECYCLE” THE TRYKE FOR USE BY ANOTHER CHILD? YES or NO

TELL US ABOUT YOUR CHILD: (Add additional page if necessary)__________________________________________

______________________________________________________________________________________________________

_______________________________________________________________________________________________________

If possible including a photo of your child will help us to obtain a sponsor for your child’s AmTryke® tricycle.

I give my permission for my child’s picture and personal information to be used in AMBUCS™ materials to help in obtaining a sponsor for the AmTryke® therapeutic tricycle.

Name: _____________________________________________________

Date: __________________________________

**AmTryke® therapeutic tricycles are distributed based on available funds and need, and individual placements of AmTryke® therapeutic tricycles are at the discretion of the local chapters.

Please mail this application, assessment and waiver to:

Mid-Cities AMBUCS™

PO Box 558, Bedford, TX 76095

AMTRYKE REQUEST , ASSESSMENT FORM AND PARENT/GUARDIAN WAIVER MUST BE RECEIVED TO PLACE CHILD ON WISH LIST.