Amtryke Request Form

Amtryke Adaptive Tricycle Request Form
(Must be filled out completely by adult rider or parent/guardian)
Recipient’s Name
Date of Request

MonthDayYear
Date
Address

Mailing Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Age
Phone #
Diagnosis
Email
example@example.com
If Recipient is Under Age 18
Parent/Guardian Name
Address

Mailing Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Parent/Guardian Phone #
Parent/Guardian Email
example@example.com
Secondary Contact Name
Secondary Phone #
Treating Therapist’s Name
Therapist Phone #
Therapist Email
example@example.com
How did you hear about the Amtryke Adaptive Tricycle? (Check all that apply)

TherapistWebsiteAMBUCS MemberOther
Note: Amtryke adaptive tricycles are distributed based on available funds and need. Individual placements of Amtryke adaptive tricycles are at the discretion of the local chapter or parent organization.

Is the recipient a U.S. Veteran?
Tell us about the recipient
This information will be made public to help obtain funding. Please don’t include information you don’t want shared.
Signature*

Clear
Date

MonthDayYear
Date
Individuals will not be considered for placement until all three forms are returned to AMBUCS: this form filled out by the recipient/guardian, as well as the Assessment Form and Tryke Selection Form filled out by the therapist.
Amtryke Adaptive Tricycle Waiver Form
(Must be filled out completely by adult rider or parent/guardian)

AMBUCS members nationwide are dedicated to creating opportunities for mobility and independence by providing Amtryke adaptive tricycles, offering educational scholarships to therapy students and performing various forms of community service.
Purpose:
The Amtryke adaptive tricycle creates a feeling of freedom, builds self-esteem, strengthens muscles and improves motor coordination and rage of motion—all while making exercise fun.
Steering:
Initially, the rider may have difficulty turning or changing directions. Encourage the rider to go straight ahead, back up and slowly turn around. On many models there are three steering options for the Amtryke. On the front column of the tricycle you will find two holes for the steering pin. The top hole is straight steering, the bottom hole allows a 20-degree turning radius. Leaving the pin out gives the rider free steering.
Safety Cautions
- Fast speeds and sharp turns can cause the Amtryke adaptive tricycle to tip or turn over.
- Always wear a helmet when riding an Amtryke. Use of other protective gear is highly recommended.
- Adult supervision required if used by younger or developmentally delayed riders.
- Use caution near vehicles, swimming pools and other bodies of water, hills, alleys and sloped driveways.
- Always wear shoes.
- Never allow more than one rider.
- Use of the steering pin is recommended to prevent over-steering or possible tip-overs.
The information contained in this service is not intended nor implied by National AMBUCS, Inc. to be professional medical advice by National AMBUCS, Inc. Always seek the advice of your physician, therapist or other qualified healthcare provider prior to staring any treatment or with any question you may have regarding a medical condition. Nothing contained in this document is intended by National AMBUCS, Inc. to be for medical diagnosis or treatment by National AMBUCS, Inc. or on behalf of National AMBUCS, Inc.

In no event shall National AMBUCS, Inc. be liable for any direct, indirect, incidental, consequential, special, exemplary, punitive, or any other monetary or other damages, personal injury or property damages, fees, fines, costs, attorney fees, or liabilities of any kind arising out of or relating in any way to this service or use of the Amtryke® adaptive tricycle, and/or content or information provided herein.
I agree that the rider listed on the front of this document may be photographed. I also agree that the photos and recipient’s name may be used in promotional efforts for National AMBUCS, Amtryke or the local AMBUCS chapter. I further grant AMBUCS the ability to use the photos and name for advertising/publicity purposes without additional compensation, except where prohibited by law. If anybody in my party does not want to be photographed under these same terms, I will let the photographer know as soon as possible.
By signing below, I acknowledge that I have read and understood this liability waiver.
Recipient’s Name
Adult Recipient Signature

Clear
If Recipient is Under Age 18
Legal Guardian Name*
Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Individuals will not be considered for placement until all three forms are returned to AMBUCS: this form filled out by the recipient/guardian, as well as the Assessment Form and Tryke Selection Form filled out by the therapist.
Submitter Info
Submitted By*

First NameLast Name
Submitter Email*
example@example.com
Submitter Phone*
Please enter a valid phone number.
Should be Empty:

Amtryke Adaptive Tricycle Request Form

If Recipient is Under Age 18

Amtryke Adaptive Tricycle Waiver Form

Purpose:

Steering:

Safety Cautions

If Recipient is Under Age 18

Submitter Info