Phone #: Email: If Recipient is Under Age 18 Parent/Guardian Name: If different from above Mailing Address: City/State/Zip: Phone #: Email: Secondary Contact Name: Phone #: Treating Therapist’s Name: Phone #: Email: How did you hear about the Amtryke Therapeutic Tricycle? (Check all that apply) □ Therapist □ Website □ AMBUCS Member □ Other: Will you need financial assistance to obtain the tricycle? If yes, how much can you pay? □ Yes □ No Note: Amtryke therapeutic tricyc.
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How to fill out the AMBUCS Amtryke Therapeutic Tricycle Request Form online
This guide provides step-by-step instructions for completing the AMBUCS Amtryke Therapeutic Tricycle Request Form online. By following these instructions, you will be able to accurately and efficiently fill out the required information to assist in the request process.
Follow the steps to complete the form accurately and efficiently.
- Click ‘Get Form’ button to obtain the AMBUCS Amtryke Therapeutic Tricycle Request Form and open it in your preferred document editor.
- Begin by entering the recipient’s name in the designated field. Ensure the name reflects the individual for whom the request is being made.
- Fill in the mailing address, including street, city, state, and zip code. This information is crucial for correspondence regarding the request.
- Indicate the recipient's diagnosis clearly. This helps in understanding the specific needs related to their condition.
- Enter the recipient's age. This information is necessary for eligibility and appropriateness of the tricycle model.
- Record the date of the request along with a primary contact number and email address for follow-up communications.
- If the recipient is under the age of 18, provide the name and contact information of the parent or guardian.
- List a secondary contact name and phone number in case the primary contact cannot be reached.
- Fill out the treating therapist’s name and their contact information. This includes a phone number and email address as this person will play a vital role in the assessment.
- Answer the question regarding how you heard about the Amtryke Therapeutic Tricycle by checking all applicable options.
- Indicate if financial assistance is needed and specify how much can be paid towards the tricycle cost, if applicable.
- Provide a brief description of the recipient, keeping in mind that this information may be made public to assist in funding.
- Include a photo of the recipient. Ensure it is a digital image or a professionally printed glossy photo, along with consent for AMBUCS to use the image for funding purposes.
- Sign and date the form to confirm that all provided information is accurate and complete.
- Once all fields are filled out, review the completed form for accuracy. Save your changes, and download a copy if necessary.
- Finally, submit the completed form by mailing, emailing, or faxing it to your local AMBUCS chapter or the AMBUCS Resource Center.
Complete your AMBUCS Amtryke Therapeutic Tricycle Request Form online today and take the next step towards mobility and independence.
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