AdaptAbility Application

Congratulations on taking the first step to help a child experience the freedom of riding a bicycle!

We are excited at the prospect of your child receiving a bike from AdaptAbility! 

In order to make sure the candidates we consider are appropriately chosen, we ask the parents/guardians of children that would like the chance to receive one of our custom bikes to fill out an application. This application is intended for us to learn about your child’s condition and your family so that we can make the most educated decision possible for who receives a bike from our program.

Your answers will not be shared with the public, they are intended for our private use. If your child is chosen, your answers will also be used by the maker of the bike to help them customize it as much as possible.

If your child is chosen to receive a bike, we also reserve the right to share some details about your child’s medical condition, his or her name, and photographs as part of our promotion of the program. You are giving us that permission by submitting this application. 

We wish you luck and please contact us at believe@adaptabilitybike.org if you have any questions.

Please know that once you begin the online application it can not be saved for a later time. You will need to restart the application if you do not have the following information:

  • Your child's PT/OT contact information          

  • Your doctor’s contact information

  • Permission from your doctor and PT (or OT) for your child to ride a bike from AdaptAbility Bike

You may email any supporting documentation to believe@adaptabilitybike.org

Documents you may choose to email us can include: 

  • PT/OT/doctor/case manager justification letter

  • Photos of your child                

  • Any information you would like to share that is not asked on the applicationp


Application

CONSENT FORM: I hereby give ADAPTABILITY sole permission to follow a line of investigation on any of the information I have provided on this application. This includes ADAPTABILITY contacting the applicant's school, agencies, care team, and or medical personnel listed anywhere on this application. I understand that ADAPTABILITY reserves the right to review and report internally and to a 3rd party the results of its review of my application as it deems appropriate. I also give AdaptAbility the right to use my child’s name, medical condition, and photographs for promotional purposes on our website, social media, printed flyers, and any other promotional material we deem necessary if my child is chosen to receive a bike from AdaptAbility. By entering your full name in the box below, you are effectively providing your signature, providing your permission to the above and indicating that all the information on this form is true and accurate, to the best of your knowledge. THIS SECTION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN IF APPLICANT IS A MINOR AND/OR CANNOT SIGN. *

 

Please complete the form below

Child's Name *
Child's Name
Parent/Guardian Name *
Parent/Guardian Name
Date*
Date*
FULL APPLICATION: all questions marked with an * are required. Answers cannot be saved so make sure to finish and submit the full application at onces.
Child's Name *
Child's Name
This information is needed for bike customization purposes.
If no, prese write "no"
If no, please write "no"
Child's Physical Therapist *
Child's Physical Therapist
http://
Child's Doctor *
Child's Doctor
http://
Please give a detailed answer
Questions about the parents/guardians
Parent/Guardian 1 *
Parent/Guardian 1
Parent/Guardian 1 contact number *
Parent/Guardian 1 contact number
Parent/Guardian 1 Home address *
Parent/Guardian 1 Home address
If no employer enter "none"
Parent/Guardian 1 Employer contact number *
Parent/Guardian 1 Employer contact number
If no employer write "none"
Please describe your physical activity per week. How often do your ride a bike, run or exercise outside per week?
Parent/Guardian 2 contact number *
Parent/Guardian 2 contact number
Parent/Guardian 2 home address
Parent/Guardian 2 home address
If no employer enter "none"
Parent/Guardian 2 employer contact number *
Parent/Guardian 2 employer contact number
If no employer enter "none"
if no employer enter "none"
Please describe your level of activity per week. How often do you ride a bike, run or exercise outside per week?
Questions about your familiy
Please choose the amount closest to your family's combined income
Please describe how active your family is on a weekly basis (as a unit) outside the home
Please describe if you are able to walk to the park or need to use a vehicle
Please describe in detail
Commitment to the program
If you answer above was yes, please type "not applicable"
Please include a photo of your child with this application by emailing it to believe@adaptabilitybike.org after you click submit