AmTryke Therapeutic Tricycle Request Form (Must be filled out completely by adult rider or parent/guardian)

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Myles Gilmore
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AmTryke Therapeutic Tricycle Request Form (Must be filled out completely by adult rider or parent/guardian) Recipient s Name: Age: Date of Request: Mailing Address: Phone #: City/State/Zip: Email:

1 AmTryke Therapeutic Tricycle Request Form (Must be filled out completely by adult rider or parent/guardian) Recipient s Name: Age: Date of Request: Mailing Address: Phone #: City/State/Zip: Diagnosis: If Recipient is Under Age 18 Parent/Guardian Name: Mailing Address: Phone #: City/State/Zip: Secondary Contact Name: Phone #: Treating Therapist s Name: Phone #: How did you hear about the AmTryke Therapeutic Tricycle? (Check all that apply) Therapist Website AMBUCS Member Other: AmTryke Demonstration Site Name: Demo Site State: Will you need financial assistance to obtain the tricycle? Yes No If yes, how much can you pay? Note: AmTryke therapeutic tricycles are distributed based on available funds and need. Individual placements of AmTryke therapeutic tricycles are at the discretion of the local chapter. Tell us about the recipient: Including a photo of the recipient will help us obtain a sponsor to help you pay for the AmTryke more quickly. By including a photo, you are giving consent for AMBUCS to use the image and personal information to help obtain a sponsor. Signature: Date: Individuals will not be considered for placement until all three forms are returned to AMBUCS: this Request and the Waiver (on reverse) filled out by the recipient/guardian, as well as the Assessment filled out by the therapist.

2 AmTryke Therapeutic 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 for people with disabilities by providing AmTryke therapeutic tricycles, offering educational scholarships to therapy students and performing various forms of community service. Purpose: Steering: The AmTryke therapeutic tricycle was designed for people with disabilities. It creates a feeling of freedom, builds self-esteem, strengthens muscles and improves motor coordination and rage of motion all while making exercise fun. Initially, the rider may have difficulty turning or changing directions. Encourage the rider to go straight ahead, back up and slowly turn around. 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. Safety Cautions Fast speeds and sharp turns can cause the AmTryke therapeutic 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 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 TM, Inc. to be professional medical advice by National AMBUCS TM, 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 service is intended by National AMBUCS TM, Inc. to be for medical diagnosis or treatment by National AMBUCS TM, Inc. or on behalf of National AMBUCS TM, Inc. In no event shall National AMBUCS TM, 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 therapeutic tricycle, and/or content or information provided herein. By signing below I agree that I may be photographed by National AMBUCS. I also agree that my photo and name may be used in promotional efforts for National AMBUCS and AmTryke LLC. I further grant National AMBUCS the ability to use the photos and name for advertising/publicity purposes without additional compensation, except where prohibited by law. Recipient s Name: Mailing Address: Phone #: City/State/Zip: If Recipient is Under Age 18 Legal Guardian Name: Legal Guardian Signature: Date: Individuals will not be considered for placement until all three forms are returned to AMBUCS: this Waiver and the Request (on reverse) filled out by the recipient/guardian, as well as the Assessment filled out by the therapist.

on Provided Measurements (if any): Total Length Total Length Helmet Sizing Size Measurement (head circumference) XXS 18.5 to 19.5 XS 20.5 to 22 S/M 22 to 23.6 L/XL 23.6 to 35.

3 AmTryke Assessment Form (Must be filled out completely by therapist) Recipient s Name: Age: Weight (lbs.): Height (inches): RIDER S MEASUREMENTS Arm Measurements (inches) Left A to B: B to C: Right A to B: B to C: Trunk A to D: Leg Measurements (inches) Left D to E: E to F: Right D to E: E to F: Notes on Provided Measurements (if any): Total Length Total Length Helmet Sizing Size Measurement (head circumference) XXS 18.5 to 19.5 XS 20.5 to 22 S/M 22 to 23.6 L/XL 23.6 to A B C D E F Center of Shoulder Center of Elbow Center of Digit Crease Center of Hip Center of Knee Bottom of Foot Arm Length & Leg Length Measurements are critical to correct AmTryke Selection Sizing Charts are available online: AmTrykeSizingChart Therapist Name: Is this the treating therapist? Yes No Credentials: Phone: Facility Name: Street Address: City: State: Zip: Is this facility an AmTryke Evaluation Site? Yes No Not Sure Diagnosis(es): Therapist comments concerning recipient or goals: This request/assessment is directed to: Local AMBUCS Chapter Name: National Wish List (AMBUCS Resource Center) Therapist Signature: Date: Ship to Address Name/Facility: Phone: Street Address: City: State: Zip:

4 Thanks for choosing an AmTryke therapeutic tricycle! In order to accommodate the widest variety of people and disabilities, AmTryke offers many tryke models and each can be customized in a variety of ways. Following the steps below will help you choose to the perfect tryke for your client from what might seem like a dizzying array of options. Remember you can always refer to our website, or the AmTryke catalogue for more information and product images. Step 1: Fill out the first page of the AmTryke Assessment form. Step 2: Choose the way the tryke will be propelled and choose from the trykes available in that category. AmTrykes can be propelled in three ways: Hand Foot, Foot, or Hand. Your choice should be based on the rider s ability and therapy goals. Hand Foot trykes improve coordination, strength and range of motion. Using all four extremities helps with weakness in any area, even general weakness, and can positively affect tone. Foot trykes were developed in response to requests from therapists for a traditional tricycle for riders with special needs. Hand trykes are for those who cannot perform and/or tolerate full foot or hip rotation. Step 3: Take rider s measurements from the Assessment form you filled out and compare them to our Sizing Chart. (This will narrow the choices considerably) Step 4: Choose a drive. (If it doesn t mention a choice, then ignore this step.) AmTrykes come with two drive possibilities: Positive Fixed and Gear. Tryke models have been carefully designed so the drive matches the therapeutic goals of the equipment; therefore all drives are not available on all trykes. A positive fixed drive, otherwise known as a fixie, helps individuals who might otherwise have problems making a full pedal rotation. The foot crank is constantly in motion for full therapeutic effect. Coasting is not possible with a positive drive; when limb motion stops, the bike does as well. Gears riders must be able to make a complete pedal rotation on their own. This tryke is suitable for riders who need help with balance and a stable sitting position but who have the cognitive ability to steer successfully and apply the coaster brake or hand brake. The key feature of gears is the ability to coast. Step 5: Chose any adaptations and/or accessories needed by the rider. Each tryke model can only be customized in the ways noted in its own model section in the following document or with the generic accessories listed below. If a customization option is not listed, it is because of design or other practical constraints in offering it on a particular model. GENERIC ACCESSORIES (not model specific) Safety Items Safety Flag License Plate Water Bottle w Cage Leg & Foot Items Foot Cups (pair): Knee Adductor Strap: Pedal Block (1 = ¾ ) qty Hand Items Small Small Large Medium Medium Brachial Plexus Kit (only for Hand & Foot Cycles) Wrist Wraps Wrist Brace Mitt: (Includes right & left) Right Left X Small Large XX Small Medium Small X Large X Small Large Medium Small X Large Hand Strap

5 FOOT TRYKES OCEANA FOOT TRYKE (with 9 front wheel fixed drive) 50 FC 0250 Arm Length 14 18inches Leg Length 16 19inches Option #1 Standard Seating System: Blue Bucket Seat Blue Bucket Seat Accessories: Seat Extender Plate (allows leg length of 12 19inches) Option #2 Upgraded Seating System: Snappy Seat System Oceana Accessories: Pull/Steering Bar Heel Pedal Leveler Pulley SNAPPY FOOT TRYKE (with 12 front wheel fixed drive) 50 FC 0150 Arm Length 9 13inches Leg Length 17 22inches Option #1 Standard Seating System: Snappy Seat System Option #2 Alternate Seating System: Blue Bucket Seat Option #3 Alternate Seating System: Saddle Seat/Gray Plastic Back/Seat Post Snappy Accessories: Pull/Steering Bar Push Bar Heavy Duty Push Bar Exercise Pedals 1412 ProSeries FOOT TRYKE (with 12 front wheel fixed drive) 50 FC 1412 Arm Length 14 22inches Leg Length 21 26inches Option #1 Standard Seating System: Saddle Seat/Gray Plastic Back with 2 chest straps Trunk Support Upgrades: ProSeries Seatback System (includes push grip backpad & 2 laterals) ProSeries Head Rest ProSeries Full Padded Back ProSeries Lumbar Pad ProSeries Back Spacer Kit H Harness: Recumbent 10 Degree Seat Post AM Full Padded Back Option #3 Upgraded Seating System: Snappy Seat System 1412 Accessories: Pull/Steering Bar Push Bar Heavy Duty Push Bar Knee Separator: 2 5 Toe Pedal Leveler Pulley Hand Brake Exercise Pedals 8 inch Hi Rise Handlebars Rear Steering Kit (NEW! Takes the place of 1500 Series.) 1416 ProSeries FOOT TRYKE (with 16 front wheel fixed drive) 50 FC 1416 Arm Length 14 22inches Leg Length 24 32inches Option #1 Standard Seating System: Saddle Seat with ProSeries Seatback System (Includes push grip, backpad & 2 laterals) Seat Bottom Alternates: Bench Seat Padded Tractor Seat with bracket Trunk Support Upgrades: ProSeries Head Rest ProSeries Full Padded Back ProSeries Lumbar Pad H Harness: Recumbent 10 Degree Seat Post 1416 Accessories: Pull/Steering Bar Push Bar Heavy Duty Push Bar Knee Separator: 2 5 Calf & Leg Support Toe Pedal Leveler Pulley 9 extender tube Hi Rise Handlebars: 8 12 Exercise Pedals Rear Steering Kit (NEW! Takes the place of 1500 Series.)

6 1420 ProSeries FOOT TRYKE (with 20 front wheel fixed drivel) 50 FC 1420 Arm Length 18 28inches Leg Length 27 35inches Option #1 Standard Seating System: Saddle Seat with ProSeries Seatback System (Includes push grip, backpad & 2 laterals) Seat Bottom Alternates: Bench Seat Padded Tractor Seat with bracket Trunk Support Upgrades: ProSeries Head Rest ProSeries Full Padded Back ProSeries Lumbar Pad H Harness: Recumbent 10 Degree Seat Post 1420 Accessories: Pull/Steering Bar Push Bar Heavy Duty Push Bar Knee Separator: 2 5 Toe Pedal Leveler Pulley Calf & Leg Support Hi Rise Handle Bars: 8 12 Rear Steering Kit (NEW! Takes the place of 1500 Series.) NEW 1616 ProSeries FOOT TRYKE (with 16 front wheel 3 speed) 50 FC 1616 Advanced Riders Only must make a pedal revolution on their own Option #1 Standard Seating System: Saddle Seat with Hi Rise Handle Bars Seat Bottom Alternates Padded Tractor Seat with bracket 1420 Accessories: Hi Rise Handle Bars: 8 12 NEW 1620 ProSeries FOOT TRYKE (with 20 front wheel 3 speed) 50 FC 1620 Advanced Riders Only must make a pedal revolution on their own Option #1 Standard Seating System: Saddle Seat with Hi Rise Handle Bars Seat Bottom Alternates Padded Tractor Seat with bracket 1420 Accessories: Hi Rise Handle Bars: FOOT TRYKE (with 20 front wheel) (rider must be able to make a pedal revolution) Select Drive Train: Single Speed (hand brake) 50 FC Speed (coaster & hand brake) 50 FC 2707 Option #1 Standard Seating System: Saddle Seat Seat Bottom Alternates: Bench Seat Padded Tractor Seat with Support Bracket: Trunk Support Upgrades: 2700 Back Support (with pad & 2 laterals) Handlebar Upgrades: 1400 Handlebar 12 Hi Rise Handlebars Dual Hand Brake Lever Stem Riser 2701 and 2707 Accessories: Exercise Pedals Expanding Pedals Heel Pedal Leveler Pulley (only w/ Expanding Pedals) Calf & Leg Support (only w/ Expanding Pedals) 2720 FOOT TRYKE (with 24 front wheel) (rider must be able to make a pedal revolution) Select Drive Train: Single Speed (hand brake) 50 FC Speed (coaster& hand brake) 50 FC 2727 Option #1 Standard Seating System: Saddle Seat Seat Bottom Alternates: Bench Seat Padded Tractor Seat with Support Bracket: Trunk Support Upgrades: 2700 Back Support (with pad & 2 laterals) Handlebar Upgrades: ProSeries Handlebars 12 Hi Rise Handlebars Dual Hand Brake Lever Stem Riser 2721 and 2727 Accessories: Exercise Pedals Expanding Pedals Heel Pedal Leveler Pulley (only w/ Expanding Pedals) Calf & Leg Support (only w/ Expanding Pedals)

7 JT 2000 FOOT TRYKE (Recumbent 21 Speed) 50 FC 2000 (advanced riders only) JT 2000 Accessories: Exercise Pedals Expanding Pedals Toe Clips Digital Speedometer Dual Hand Brake Stem Extender Mirrors Therapist Assembly Notes or Comments (if any):

8 HAND FOOT TRYKES AM 9XXS HAND FOOT TRYKE (with 2.5 crank arms, Snappy Seat System w/notched bottom seat cushion) 50 HFC 0102XXS Arm length inches, leg length inches Snappy Seat Accessories: Notched Wide Bottom Cushion AM 9XXS Accessories: Pull/Steering Bar Heel Pedal Leveler Pulley AM 9XS HAND FOOT TRYKE (with seat extender plate, 2.5 crank arms) 50 HFC 0102XS Arm length inches, leg length inches Option #1 Standard Seating System: Blue Bucket Seat Option #2 Upgraded Seating System: Snappy Seat System AM 9XS Accessories: Pull/Steering Bar Heel Pedal Leveler Pulley AM 9S HAND FOOT TRYKE (with 4 crank arms) 50 HFC 0102S Option #1 Standard Seating System: Blue Bucket Seat Option #2 Upgraded Seating System: Snappy Seat System AM 9S Accessories: Pull/Steering Bar Heel Pedal Leveler Pulley Arm length inches, leg length inches AM 12 Small HAND FOOT TRYKE (with 3 crank arms & 12 front wheel) 50 HFC 0110 Arm length inches, leg length inches Option #1 Standard Seating System: Snappy Seat Bottom & Gray Plastic Back Option #2 Upgraded Seating System: Snappy Seat System AM 12S Accessories: Pull/Steering Bar Toe Pedal Leveler Pulley Exercise pedals Push Bar Heavy Duty Push Bar AM 12 HAND FOOT TRYKE (with 12 front wheel) 50 HFC 0210 Arm length inches, leg length inches Option #1 Standard Seating System: Saddle Seat/Gray Plastic Back Trunk Support Upgrades: 1400 ProSeries Seatback (includes push grip backpad & 2 laterals) 1400 ProSeries Lumbar Pad 1400 ProSeries Back Spacer Kit 1400 ProSeries Head Rest 1400 ProSeries Full Padded Back H Harness: AM Full Padded Back Option #3 Upgraded Seating System: Snappy Seat System AM 12 Accessories: Pull/Steering Bar Toe Pedal Leveler Pulley Exercise pedals Push Bar Heavy Duty Push Bar Knee Separator: 2 5

9 AM 16 HAND FOOT TRYKE (with 16 front wheel) 50 HFC 0411 Arm length inches, leg length inches Option #1 Standard Seating System: Saddle Seat/Gray Plastic Back Seat Bottom Upgrades: Bench Seat Trunk Support Upgrades: 1400 ProSeries Seatback (includes push grip backpad & 2 laterals) 1400 ProSeries Lumbar Pad 1400 Proseries Back Spacer Kit Padded Tractor Seat (used with 1400 ProSeries Seatback only) 1400 ProSeries Head Rest 1400 ProSeriesFull Padded Back H Harness: AM Full Padded Back AM 16 Accessories: Pull/Steering Bar Toe Pedal Leveler Pulley Exercise pedals Push Bar Heavy Duty Push Bar Knee Separator: 2 5 Knee Separator 9 Extender Tube Therapist Assembly Notes or Comments (if any):

10 HAND TRYKES SWIRLYGIG HAND TRYKE 50 HC 500 Arm Length 14 20inches Option #1 Standard Seating System: Snappy Seat System Snappy Seat Accessories: Notched Seat Bottom Cushion Option #3 Upgraded Seating System: Snappy Seat System w/ Wide Notched Seat Cushion & Extra Large Seat Back AM 9XS HAND TRYKE (with Seat Extender Plate, 2.5 Crank Arms & Permanent Foot Platform) 50 HC 0900XS Arm Length 11 14inches Option #1 Standard Seating System: Blue Bucket Seat Option #2 Upgraded Seating System: Snappy Seat System AM 9S HAND TRYKE (4 Crank Arms & Permanent Foot Platform) 50 HC 0900 Arm Length 14 18inches Option #1 Standard Seating System: Blue Bucket Seat Option #2 Upgraded Seating System: Snappy Seat System AM 12Small HAND TRYKE (with 12 Front Wheel & Permanent Foot Platform) 50 HC 0210S Arm Length 12 15inches Option #1 Standard Seating System: Snappy Notched Seat Bottom/Gray Plastic Back Trunk Support Upgrades: AM Full Padded Back H Harness: Back Spacer Kit AM 12Small Accessories: Pull/Steering Bar Push Bar Heavy Duty Push Bar Knee Separator: 2 5 AM 12 HAND TRYKE (with 12 Front Wheel & Permanent Foot Platform) 50 HC 0210 Arm Length 14 18inches Option #1 Standard Seating System: Saddle Seat/Gray Plastic Back Trunk Support Upgrades: ProSeries Seatback (includes push grip backpad & 2 laterals) ProSeries Lumbar Pad ProSeries Head Rest ProSeries Full Padded Back Back Spacer Kit H Harness: AM Full Padded Back Option #3 Upgraded Seating System: Snappy Seat System AM 12 Accessories: Pull/Steering Bar Push Bar Heavy Duty Push Bar Knee Separator: 2 5

11 AM 16 HAND TRYKE (with 16 Front Wheel & Permanent Foot Platform) 50 HC 0411 Arm Length 18 26inches Option #1 Standard Seating System: Saddle Seat/Gray Plastic Back Seat Bottom Upgrades: Bench Seat Padded Tractor Seat (w/proseries Seatback only) Trunk Support Upgrades: ProSeries Seatback (includes push grip backpad & 2 laterals) ProSeries Head Rest ProSeries Full Padded Back ProSeries Lumbar Pad Back Spacer Kit H Harness: AM Full Padded Back AM 16 Accessories: Pull/Steering Bar Push Bar Heavy Duty Push Bar Knee Separator: 2 5 Knee Separator 9 Extender Tube COMMUNITY CRUISER HAND TRYKE (24 Front Wheel & 3 Speed Drive Train) 50 HC 1424 CC Accessories: Wheelchair Seat Bar Ends Swing Away Arms HP 1000 RECREATION HAND TRYKE (7 Speed Drive Train) 50 HC 1000 HP 1000 Accessories: Wheelchair Seat Bar Ends Swing Away Arms Therapist Assembly Notes or Comments (if any):

AMTRYKE SIZING CHART MOTION CONTROLLED MODEL RIDER LEG LENGTH (Inches) (Center of hip to bottom of shoe) RIDER ARM LENGTH (Inches) (Middle of shoulder to center of digit crease) RIDER WEIGHT (lbs)

HEIGHT (Inches) TRYKE WEIGHT (lbs) WHEEL SIZE (Inches) FRAME HEIGHT (Inches) (Without seat) TOTAL LENGTH (inches) (With push bar add 24") TRYKE WIDTH (Inches) Hand/Foot AM-9XXS 10-15 10-14 150 36 55

12 AMTRYKE SIZING CHART MOTION CONTROLLED MODEL RIDER LEG LENGTH (Inches) (Center of hip to bottom of shoe) RIDER ARM LENGTH (Inches) (Middle of shoulder to center of digit crease) RIDER WEIGHT (lbs) RIDER MAX. HEIGHT (Inches) TRYKE WEIGHT (lbs) WHEEL SIZE (Inches) FRAME HEIGHT (Inches) (Without seat) TOTAL LENGTH (inches) (With push bar add 24") TRYKE WIDTH (Inches) Hand/Foot AM-9XXS Front 9 Rear 6.5 Hand/Foot AM-9XS Front 9 Rear 6.5 Hand/Foot AM-9S Front 9 Rear Hand/Foot AM-12S Hand/Foot AM Hand/Foot AM Front 16 Rear 12 Foot Oceana Front 9 Rear Foot Snappy Foot 1412/ Foot 1416/ / Foot Foot Foot Foot Hand Hand 1420/ / / / JT Front 16 Rear Swirlygig Hand HP Front 16 Rear A Center of Shoulder B Center of Elbow C Center of Digit Crease D Center of Hip E Center of Knee F Bottom of Foot RIDER'S MEASUREMENTS Arm Measurements (inches) Total Length Left A to B B to C Right A to B B to C Trunk A to D Leg Measurements (inches) Total Length Left D to E E to F Right D to E E to F HELMET SIZING Youth Sizes Head Circumference Inches XXS 18.5 to 19.5 XS 20.5 to 22 SM 22 to 23 5/8 L 23 5/8 to 25 3/4 Adult Sizes Head Circumference Inches S/M 22 to 23 5/8 L/XL 23 5/8 to 25 3/4

Amtryke Therapeutic Tricycle Request Form (Must be filled out completely by adult rider or parent/guardian)

Amtryke Therapeutic Tricycle Request Form (Must be filled out completely by adult rider or parent/guardian) Recipient s Name: Age: Date of Request: Mailing Address: Phone #: City/State/Zip: Email: Diagnosis: