AMBUCS Amtryke Therapeutic Tricycle Request Form 2015-2025 free printable template

Leaving the pin out gives the rider free steering. Safety Cautions Fast speeds and sharp turns can cause the Amtryke therapeutic tricycle to tip or turn over. Amtryke Therapeutic Tricycle Request Form Must be filled out completely by adult rider or parent/guardian Recipient s Name Mailing Address City/State/Zip Diagnosis Age Date of Request Phone Email If Recipient is Under Age 18 Parent/Guardian Name If different from above Secondary Contact Name Treating Therapist s Name How did you hear...

How to fill out form amtryke therapeutic

How to fill out AMBUCS Amtryke Therapeutic Tricycle Request Form

1. Obtain the AMBUCS Amtryke Therapeutic Tricycle Request Form from the official website or local AMBUCS chapter.
2. Fill in the personal information of the child or individual in need at the top of the form, including name, age, and contact details.
3. Provide detailed information about the individual's physical or developmental challenges that necessitate the use of a therapeutic tricycle.
4. Select the appropriate Amtryke model based on the individual's needs and preferences, ensuring to review the specifications and size options.
5. Include any necessary medical documentation or recommendations from healthcare professionals that support the request.
6. Submit the completed form along with any required documents to your local AMBUCS chapter or the designated mailing address.

Who needs AMBUCS Amtryke Therapeutic Tricycle Request Form?

1. Children or individuals with physical or developmental disabilities who require mobility assistance and would benefit from therapeutic outdoor activities.

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What is AMBUCS Amtryke Therapeutic Tricycle Request Form?

The AMBUCS Amtryke Therapeutic Tricycle Request Form is a document used to request an Amtryke therapeutic tricycle for individuals with physical disabilities, aimed at enhancing their mobility and therapeutic activity.

Who is required to file AMBUCS Amtryke Therapeutic Tricycle Request Form?

The form is typically required to be filed by caregivers, parents, or guardians of children with physical disabilities who are seeking to obtain an Amtryke therapeutic tricycle.

How to fill out AMBUCS Amtryke Therapeutic Tricycle Request Form?

To fill out the form, applicants need to provide personal information of the individual requesting the tricycle, details about the disability, the intended use of the tricycle, and any specific needs or adaptations required.

What is the purpose of AMBUCS Amtryke Therapeutic Tricycle Request Form?

The purpose of the form is to facilitate the request and approval process for obtaining an Amtryke therapeutic tricycle, ensuring that individuals have the necessary mobility aids for therapeutic and recreational use.

What information must be reported on AMBUCS Amtryke Therapeutic Tricycle Request Form?

The information required includes the individual's name, age, disability details, the type of tricycle requested, any specific adaptations necessary, and contact information for the requester.