Ambucs Web Site

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

Request for AmTryke® therapeutic tricycle
Application Form

Name:

Date of Request:

Address:

City:

State:

Zip:

E-mail Address:

Phone:

Name of Recipient:

Age of Recipient:

Height: Weight:

Diagnosis of Recipient:

Type of Therapy Recipient is Receiving:

Therapist's Name:

Title/Field:

Phone:

Therapist E-Mail Address:

Will the child benefit from use of the Amtryke? Yes No

Therapist Certification:
I certify that the information provided is correct Yes No

Size of Amtryke Requested: 8" 12" 16" All Terrian

How did you hear about the AmTryke (Check all that apply):
Therapist Friend Website
AMBUCS Member Media
Other (Specify)

Is financial assistance needed in obtaining the AmTryke? Yes No

How much can you afford to pay?

How much do you need help with?

You agree to return the AmTryke® tricycle to AMBUCS™ when the recipient can no longer benefit from the use of it so that it may be "recycled" for use by another child? Yes

Comments:

Request for AmTryke® therapeutic tricycle Application Form

Request for AmTryke® therapeutic tricycle
Application Form