Adaptive Trike Waitlist Parent/Guardian Name / Nombre del Padre/Guardián* First Last Relationship to Participant / Relación con el Participante*Preferred Language of Parent/Guardian? / Idioma Preferido del Padre/Guardián* English Español Other Parent/ Guardian Preferred Email / Correo Electrónico Preferido del Padre/Guardián* Primary Phone Number / Número de Teléfono*Address / Dirección* Street Address Line 1 /Dirección Línea 1 Address Line 2 / Dirección Línea 2 City / Ciudad ZIP / Postal Code – Código Postal Patient Name* First / Nombre Last / Apellido Patient Date of Birth Patient Height*Patient Weight*How often would you take your child on tricycle rides? 1-2 times a week 3-4 times a week 5 or more times a week Other Where would you most commonly have your child ride their tricycle? Is it paved? Level?*Adaptive tricycles must be cared for and stored properly. Do you have space in your home or garage to store your child's tricycle?*Some tricycles are difficult to transport; do you have means of transporting your child's tricycle?*Tricycles require basic regular maintenance (tire repair, brakes and steering adjustments) that the Children'sClinic won't be able to provide. Are you able to maintain your child's tricycle?*Are you willing to commit to participating in any of the following programs and events once receiving your adaptive tricycle? Please check all that apply. El Tour de Tucson Fun Ride (once a year in November) Children’s Clinics Walk, Ride, or Roll Event (1-2 times a year) Southern Arizona Adaptive Sports Cycling program (ongoing program) Please put the dollar amount you are able to contribute to your Adaptive Trike.Are you interested in creating a fundraising page through Children's Clinics to help raise funds for your adaptive tricycle? Yes No Please tell us about why you would like an adaptive tricycle and how your child would benefit from receiving an adaptive tricycle.
