Parents Section » Survey

In order to better accommodate the needs of our visitors we have constructed a short survey for you, as a parent. We appreciate your input and hope that we can better serve you through our web site with the information we receive.

It is not necessary for you to input any personal information, but it is appreciated.

If preferred you can print this page, and fax/mail it to us.

Name:
Address:
City:
Province / State:
Postal Code / Zip:
Day-Time Phone:
Email:
Name of Child's Disability:
Name of Child:
Age of Child:
Gender of Child:
Which Magazines Do You Subscribe To? Exceptional Parent
Active Living
Quest
New Mobility
Able Magazine
Palaestra Magazine
APTA
OTA
Rehab Report
Disabled Dealer
Other
How Did You Hear of Us?
Is Your Child's School Equipped With a Therapeutic Mobility Device?
If Yes, What Type of Equipment is Provided?
If No, Who Can We Contact to Introduce the Idea?
Does Your Child Attend:
If Applicable, Please Enter the Name of the School Your Child Attends:
Is Your Child Currently Receiving Physiotherapy?
Do You Belong To Or Are Involved With: Cerebral Palsy
Spina Bifida
Muscular Dystrophy
Multiple Sclerosis
Other
If You Selected Other, Please Describe:
Have You Ever Purchased a Mobility Device For Your Child?
Does Your Insurance Company Cover The Cost of Mobility Devices?
What Is The Name of Your Insurance Company?
Are there any Organizations or Associations in your area that would consider funding a mobility device? Please specify.
Would You Be Interested In Hosting A Bike Day In Your Area?
Other Comments or Questions:
 
 
 

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