How To Apply

Creating Mobility and Independence for People with Disabilities

To begin the application process to obtain an AmTryke, either fill out the online form below and submit or download the CombinedWaiverRequestForm and fax, mail, or email to 786.549.2370 or tami.tubell@huntsvilleambucs.org. You will be contacted for an appointment with one of our volunteer therapist to schedule a fitting time.

Note that the downloadable file has the National AMBUCS mailing address for submission. Please use our local address for faster service. Mail to HSV TN VALLEY AMBUCS C/O CINDY PERKINS, 9299 SEGERS ROAD, MADISON, AL 35756

Applicants are then added to our WishList until funding is obtained and bikes ordered. We also encourage you to become a member of our organization and volunteer your time and services so that others may enjoy the AmTryke experience! Membership applications are located under the ‘Get Involved’ tab on the main menu.

If you are human, leave this field blank.

RECIPIENT'S NAME:

DATE OF REQUEST

AGE

STREET ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

EMAIL ADDRESS

PARENT/GUARDIAN NAME

(IF RECIPIENT UNDER AGE 18)

DIAGNOSIS

TREATING THERAPIST NAME

HOW DID YOU HEAR ABOUT AMBUCS/AMTRYKES?

IS FINANCIAL ASSISTANCE NEEDED IN OBTAINING THE AMTRYKE?

IF YES, HOW MUCH CAN YOU PAY?

I AGREE TO RECYCLE THE AMTRYKE

YES

TELL US ABOUT THE AMTRYKE RECIPIENT

PHOTO RELEASE: I give my permission for my or my child’s picture and personal information to be used in AMBUCS™ materials to help in obtaining a sponsor *

Typing your name here is acceptance of the above terms. Please sign and add today's date.

AMTRYKE THERAPEUTIC TRICYCLE WAIVER

STEERING

SAFETY

WAIVER

AMBUCS™ members nationwide are dedicated to creating opportunities for mobility and independence for people with disabilities by performing community service, providing AmTryke® therapeutic tricycles to people with disabilities, and providing scholarships for therapists. 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 starting any treatment or with any question you may have regarding a medical condition. Nothing contained in this service 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® therapeutic tricycle, and/or content or information provided herein.

ACCEPTANCE

SIGNATURE

One

Download AmTryke Application

[pdf http://tanstrat.com/hsvambucs/wp-content/uploads/2011/10/fillable-amtrykerequestform.pdf 490 700]

Huntsville TN Valley AMBUCS

How To Apply

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