Ambucs Web Site

AmTryke Demonstration Site
Application Form

By completing this form you accept a donation of an AmTryke, a therapeutic tricycle for children with disabilities. In so doing the agency will make this site available to therapists, parents, and their children with disabilities to evaluate the appropriateness of an AmTryke for a particular youngster. Times will be at the discretion of the facility. The facility agrees to allow AMBUCS to include their name and contact information in promotional listings of AmTryke Demonstration Sites. Entire form must be completed for consideration.

My facility already has an Amtryke and would like to become a demonstration site.
My facility does not have an Amtryke and would like to become a demonstration site.
Date:
Name of Facility:
Type of Facility:
Address:
City:
State:	Zip:
Contact Person:
E-mail Address:
Phone:	Fax:

Explain why your facility should be chosen to become an AmTryke Demonstration Site:

I certify that I am authorized to commit my facility to become an AmTryke Demonstration Site. In doing so, I understand and accept the terms stated above.

Applicant's Name

AmTryke Demonstration Site Application Form

AmTryke Demonstration Site
Application Form