Ambucs Web Site: AmTryke® Therapeutic Tricycle Registration Form

AmTryke® Therapeutic Tricycle Registration Form

Please take a moment to complete this form to help AMBUCS ** make this AmTryke® therapeutic tricycle the therapeutic tool we need it to be to help you, your child, and other children in the future. If you would like to file this form online, the information is at the bottom of this page.

Name of the Tryke recipient:

Name of the Parent or Guardian:

Address:

City:

State:

Zip:

Recipient's year of birth:

E-mail Address:

Phone:

Size of Amtryke Requested:

8" 12" 16" All Terrian

Tryke Serial Number:

Therapist that evaluated the recipient, if any:

AMBUCS Chapter or other purchaser of the Tryke:

What publications do you receive that relate to the recipient's diagnosis?

When your child outgrows the AmTryke® therapeutic tricycle will you "Recycle the Cycle" for use by another child?	Yes No
If your AmTryke® therapeutic tricycle is a smaller size, and your child outgrows it, would you be interested in a larger size:	Yes No
May we follow up on the recipient's progress with the AmTryke® therapeutic tricycle:	Yes No

I have read and understand the AmTryke® Therapeutic Tricycle Waiver.
Date:

** Supported by charitable contributions from National AMBUCS, Inc.