child with assistive technology in a field

High Demand Equipment

These are the items most requested by families. Donating any of these helps a child right away.

Medical Umbrella Strollers

Medical Umbrella Stroller example

Examples: Convaid Cruiser, Leggaro Reach, Swifty stroller

Activity Chairs

Rifton Activity Chair
Special Tomato Floor Sitter
Leckey Squiggles Seat

Examples: Rifton Activity Chair, Special Tomato Floor Sitter, Leckey Squiggles Seat, GoTo

Gait Trainers / Walkers

Gait Trainer
Walker

Examples: Pacer gait trainer, Crocodile gait trainer, Nimbo walker

Adaptive Tricycles

Adaptive Tricycle

Helps kids build strength, coordination, and independence

Have one of these to donate? Contact us here. Thank you.

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The below information is required for our record keeping and equipment fitting purposes.

Parent/Guardian Info

Parent/Guardian Name
Parent/Guardian Phone
Parent/Guardian Email

Therapist Info

Therapist Name
Therapist Phone
Therapist Email

Child Info

Child Name
Race
Age
Height
Weight

Other Info

Why did you choose to obtain an AT device/service from our program?
What type of insurance does the child have?
Has the requested equipment been denied by Insurance?
Persons in Household
Family Income Range
Is this child currently a client of the Department of Aging and Rehabilitative Services (DARS)?
Diagnosis
The primary reason for which the child and family needs an AT device or service is related to:
Will equipment be used at home, school or both?
Which of the following reflects your level of satisfaction with this means of obtaining needed equipment?
Order Notes (optional)

Please Note:

The fields above are required to complete your equipment request. We also require a signed Equipment Release Form to process your request. Please sign the Equipment Release Form at the button below.

Equipment Release

Please Read and Sign before submitting your request.

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