Mobility is medicine for the complete family.

ADAPTABILITY

New programs to help the community

Recycle it

• Build it

• Adapt it

• Recycle it • Build it • Adapt it •

Applications

Congratulations on taking the first step to help a child experience the freedom of riding a bicycle!

Please read carefully. Four different applications for four different programs.

Please apply below for the program that will benefit your child the most.

AdaptAbility Programs.

AdaptAbility

Program created in 2017 for the purpose of helping families with children with special needs to increase mobility, exercise, and to enjoy the pleasure of riding a bicycle while all the members of the family are together. Adapt Ability provides custom adaptive bicycles to children with special needs. Each bicycle is tailored to the child's challenges and goals. Adapt Ability bicycles are donated to families free of charge, allowing them to increase their quality of life. Our main sources of income are grants and donations. Application for the program is necessary.

AdaptAbility Application

Donation of a Custom Adaptive Bicycle for a child with special need at no cost to the family.

This application is intended for us to learn about your child’s condition and your family. Your information will allow us to make the best educated decision possible for the recipient of the adaptive bicycle.

Your answers will not be shared with the public, they are intended for our private use.

If your child is chosen to receive an adaptive bicycle, we also reserve the right to share some details about your child’s medical condition, his or her name, and photographs as part of our promotion of the program. You are giving us that permission by submitting this application.

Please know that once you begin the online application, the application cannot be saved for a later time and you will need to restart the application.

Information needed to complete application:

Child's PT/OT contact information
Child’s Doctor’s contact information
Authorization’s Letter from Child’s Doctor and PT/OT for the use of an adaptive bicycle (Supporting Documentation).
Recommendation’s Letter from Child’s Doctor and PT/OT for the use of an adaptive bicycle (Supporting Documentation).
Child’s Photos (Supporting Documentation).
Any information you would like to share that is not asked on the application.

You may email any supporting documentation to believe@adaptabilitybike.org

AA Application

Consent Form:

CONSENT FORM: I hereby give ADAPTABILITY sole permission to follow a line of investigation on any of the information I have provided on this application. This includes ADAPTABILITY contacting the applicant's school, agencies, care team, and or medical personnel listed anywhere on this application. I understand that ADAPTABILITY reserves the right to review and report internally and to a 3rd party the results of its review of my application as it deems appropriate. I also give AdaptAbility the right to use my child’s name, medical condition, and photographs for promotional purposes on our website, social media, printed flyers, and any other promotional material we deem necessary if my child is chosen to receive an adaptive bicycle from ADAPTABILITY. By entering your full name in the box below, you are effectively providing your signature, providing your permission to the above and indicating that all the information on this form is true and accurate, to the best of your knowledge. THIS SECTION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN IF APPLICANT IS A MINOR AND/OR CANNOT SIGN. *

Child's Name

First Name

Last Name

Parent/Guardian's Name

First Name

Last Name

Email

Application Date

MM

DD

YYYY

Child's Date of Birth

MM

DD

YYYY

Gender

Child's age

Child's weight(in pounds)

Child's height(in inches)

Describe the child's special needs or disabilities and when did it start?

Child's School Name

Number of days per week the Child goes to physical therapy

Does your child's physical therapy include a bicycle? Please describe. If a bicycle is not included, please say so.

Does your child receive physical therapy at home? Please describe.

Child's Doctor's Name

First Name

Last Name

Doctor's Email

Doctor's Phone Number

Country

(###)

###

####

Child's Physical Therapist's Name

First Name

Last Name

Child's Physical Therapist's Email

Child's Physical Therapist's Phone Number

Country

(###)

###

####

Do you have authorization(s) and recommendation(s) from your child's Doctor and therapist for your child to ride an adaptive bicycle? If yes, please email any supporting email to believe@adaptabilitybike.org

How active is your child? Please give a detailed answer.

Questions about Parents and Guardians

Parent/Guardian 1 Name

First Name

Last Name

Parent/Guardian 1 Phone Number

Country

(###)

###

####

Parent/Guardian 1 Email

Parent/Guardian 1 Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 1 Employer's Name

First Name

Last Name

Parent/Guardian 1 Employer's Phone Number

Country

(###)

###

####

Parent/Guardian 1 Employer's Website

http://

Parent/Guardian 1 Level of physical activity

Please describe your physical activity per week. How often you ride a bike, run, exercise outside or at the gym.

Parent/Guardian 2 Name

First Name

Last Name

Parent/Guardian 2 Phone Number

Country

(###)

###

####

Parent/Guardian 2 Email

Parent/Guardian 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 2 Employer's Name

First Name

Last Name

Parent/Guardian 2 Employer's Phone Number

Country

(###)

###

####

Parent/Guardian 2 Employer's Website

http://

Parent/Guardian 2 Level of physical activity

Please describe your physical activity per week. How often you ride a bike, run, exercise outside or at the gym.

Questions about your family

What is your combined Family Income

Please choose the closest to your combined family Income

How many children do you have?

How active is your family?

Please describe how active your family is on a weekly basis(as a unit outside the home)?

How far do you live from a park suitable for bike riding? What is the name of the park?

Please describe if you can walk to the park or you need the use of a vehicle.

Do you have a suitable storage for a large bicycle with easy access?

Please describe in detail.

Commitment to the program

This program exist because of many wonderful people who participate in different ways, mostly through donations. If your child is selected to receive an AdaptAbility bicycle, are you willing to commit to raising a minimum of $1,000 towards a bicycle for another child in the program? Is your family able to make this commitment? *

If your family is not able to make this financial commitment to help the program continue, is there another way you can contribute to help this program continue to help children experience the freedom or riding a bicycle?

if your answer above was yes, please type, "not applicable"

How did you hear about AdaptAbility?

We wish you luck and please contact us at believe@adaptabilitybike.org if you have any questions or concerns. THANK YOU

AdaptAbility 4Schools

AdaptAbility 4School is a free program for schools that allows them to rent adaptive bicycles for children with special needs to be ridden in the school. Children with special needs will have the opportunity to increase mobility, therapy, exercise, socialize with others and increase their self-esteem. With this, they will experience the outdoors in a completely different way by exercising, leaving their walkers and wheelchairs. Cycling will help with their physical therapy and health improvement and the outdoors will give them freedom and relaxation.

AdaptAbility 4School Application

Rental of Adaptive Bicycle for a child with special needs at no cost to the family.

AdaptAbility 4School is a free program created for families with children with special needs that will allow them to rent adaptive bicycles in the park and other locations. Application and reservations are needed.

This application is intended for us to learn about your child’s condition and your family. Your information will allow us to make the best educated decision possible for the rental of the adaptive bicycle.

Your answers will not be shared with the public, they are intended for our private use.

We also reserve the right to share some details about your child’s medical condition, his or her name, and photographs as part of our promotion of the program. You are giving us that permission by submitting this application.

Please know that once you begin the online application, the application cannot be saved for a later time and you will need to restart the application.

Information needed to complete application:

Child's PT/OT contact information
Child’s Doctor’s contact information
Authorization’s Letter from Child’s Doctor and PT/OT for the use of an adaptive bicycle (Supporting Documentation).
Recommendation’s Letter from Child’s Doctor and PT/OT for the use of an adaptive bicycle (Supporting Documentation).
Child’s Photos (Supporting Documentation).
Any information you would like to share that is not asked on the application.

You may email any supporting documentation to believe@adaptabilitybike.org

AA 4School Application

I hereby give ADAPTABILITY sole permission to follow a line of investigation on any of the information I have provided on this application. This includes ADAPTABILITY contacting the applicant's school, agencies, care team, and or medical personnel listed anywhere on this application. I understand that ADAPTABILITY reserves the right to review and report internally and to a 3rd party the results of its review of my application as it deems appropriate. I also give AdaptAbility the right to use my child’s name, medical condition, and photographs for promotional purposes on our website, social media, printed flyers, and any other promotional material we deem necessary if my child is chosen to rent an adaptive bicycle from ADAPTABILITY. By entering your full name in the box below, you are effectively providing your signature, providing your permission to the above and indicating that all the information on this form is true and accurate, to the best of your knowledge. THIS SECTION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN IF APPLICANT IS A MINOR AND/OR CANNOT SIGN. *

Please sign:

Date of Application

MM

DD

YYYY

Child's Applicant Name

First Name

Last Name

Child's Applicant Guardian

First Name

Last Name

Email

Phone

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

FULL APPLICATION: all questions marked with an * are required. Answers cannot be saved so make sure to finish and submit the full application at onces.

Child Date of Birth

MM

DD

YYYY

Gender

Child's Age

Child's Height

Child's Weight

Describe child's special needs or disability and when it started

Number of days per week child goes to physical therapy?

Does your child's physical therapy include the use of a bicycle?

Do you have authorization(s) and recommendation (s) from your child's doctor and therapist for you child to ride an adaptive bicycle?

If yes, please email any supporting documentation to believe@adaptabilitybike.org

Does the child had ever rode an adaptive bicycle before?

How did you hear about Adapt Ability

Date

Rental Date

MM

DD

YYYY

Time

Rental Time

Hour

Minute

Second

Rental Time

How long the rental will be for

Helmet

Helmets are required for the rental. Please bring your helmet or Do you need a helmet?

Helmet Selection

If you don't have a helmet, please let us know the size you will need.

AdaptAbility 4Ride Kids

Program created in 2019.

After working with adaptive bicycles for two years, learning how expensive it is to customize adaptive bicycles and understanding a sad conclusion that not every family in need of an adaptive bicycle can have one, we have decided to create a program where families can rent adaptive bicycles at no charge.

AdaptAbility 4Ride is a free program for children with special needs that allow families to rent adaptive bicycles for the purpose of increasing mobility, therapy, exercise or just for a fun day in the park. Application and reservations for the program are necessary.

AdaptAbility 4Ride Kids Application

Rental of Adaptive Bicycle for a child with special needs at no cost to the family.

AdaptAbility 4Ride is a free program created for families with children with special needs that will allow them to rent adaptive bicycles in the park and other locations. Application and reservations are needed.

This application is intended for us to learn about your child’s condition and your family. Your information will allow us to make the best educated decision possible for the rental of the adaptive bicycle.

Your answers will not be shared with the public, they are intended for our private use.

We also reserve the right to share some details about your child’s medical condition, his or her name, and photographs as part of our promotion of the program. You are giving us that permission by submitting this application.

Please know that once you begin the online application, the application cannot be saved for a later time and you will need to restart the application.

Information needed to complete application:

Child's PT/OT contact information
Child’s Doctor’s contact information
Authorization’s Letter from Child’s Doctor and PT/OT for the use of an adaptive bicycle (Supporting Documentation).
Recommendation’s Letter from Child’s Doctor and PT/OT for the use of an adaptive bicycle (Supporting Documentation).
Child’s Photos (Supporting Documentation).
Any information you would like to share that is not asked on the application.

You may email any supporting documentation to believe@adaptabilitybike.org

AA 4Ride Application

I hereby give ADAPTABILITY sole permission to follow a line of investigation on any of the information I have provided on this application. This includes ADAPTABILITY contacting the applicant's school, agencies, care team, and or medical personnel listed anywhere on this application. I understand that ADAPTABILITY reserves the right to review and report internally and to a 3rd party the results of its review of my application as it deems appropriate. I also give AdaptAbility the right to use my child’s name, medical condition, and photographs for promotional purposes on our website, social media, printed flyers, and any other promotional material we deem necessary if my child is chosen to rent an adaptive bicycle from ADAPTABILITY. By entering your full name in the box below, you are effectively providing your signature, providing your permission to the above and indicating that all the information on this form is true and accurate, to the best of your knowledge. THIS SECTION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN IF APPLICANT IS A MINOR AND/OR CANNOT SIGN. *

Please sign:

Date of Application

MM

DD

YYYY

Child's Applicant Name

First Name

Last Name

Child's Applicant Guardian

First Name

Last Name

Email

Phone

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

FULL APPLICATION: all questions marked with an * are required. Answers cannot be saved so make sure to finish and submit the full application at onces.

Child Date of Birth

MM

DD

YYYY

Gender

Child's Age

Child's Height

Child's Weight

Describe child's special needs or disability and when it started

Number of days per week child goes to physical therapy?

Does your child's physical therapy include the use of a bicycle?

Do you have authorization(s) and recommendation (s) from your child's doctor and therapist for you child to ride an adaptive bicycle?

If yes, please email any supporting documentation to believe@adaptabilitybike.org

Does the child had ever rode an adaptive bicycle before?

How did you hear about Adapt Ability

Date

Rental Date

MM

DD

YYYY

Time

Rental Time

Hour

Minute

Second

Rental Time

How long the rental will be for

Helmet

Helmets are required for the rental. Please bring your helmet or Do you need a helmet?

Helmet Selection

If you don't have a helmet, please let us know the size you will need.

AdaptAbility 4Ride Adults

AdaptAbility 4Ride Adult is a program created and launched in 2019 for the purpose of helping adults with disabilities to increase mobility, therapy, exercise and to enjoy a ride in the park. AdaptAbility 4Ride is a free program for adults with disabilities that allows them to rent an adaptive bicycle in the park and other locations. Individuals with disabilities will have the opportunity to socialize with others and increase their self-esteem. With this, they will experience the outdoors in a completely different way by exercising. Cycling will help with their physical therapy and health improvement and the outdoors will give them freedom and relaxation. Application and reservations are necessary.

AdaptAbility 4Ride Adult Application

Rental of Adaptive Bicycle for an adult with disabilities at no cost.

AdaptAbility 4RideAdult is a free program created for adults with disabilites that will allow them to rent adaptive bicycles in the park and other locations. Application and reservations are needed.

This application is intended for us to learn about your condition. Your information will allow us to make the best educated decision possible for the rental of the adaptive bicycle.

Your answers will not be shared with the public, they are intended for our private use.

We also reserve the right to share some details about your condition, his or her name, and photographs as part of our promotion of the program. You are giving us that permission by submitting this application.

Please know that once you begin the online application, the application cannot be saved for a later time and you will need to restart the application.

Information needed to complete application:

Adult P/T contact information (if apply)
Adult Doctor’s contact information
Authorization’s Letter from Adult’s Doctor and PT/OT for the use of an adaptive bicycle (Supporting Documentation).
Recommendation’s Letter from Adult’s Doctor and PT/OT for the use of an adaptive bicycle (Supporting Documentation).
Adult’s Photos (Supporting Documentation).
Any information you would like to share that is not asked on the application.

You may email any supporting documentation to believe@adaptabilitybike.org

AA 4Ride Adult

I hereby give ADAPTABILITY sole permission to follow a line of investigation on any of the information I have provided on this application. This includes ADAPTABILITY contacting the applicant's school (if applicable), agencies, care team, and or medical personnel listed anywhere on this application. I understand that ADAPTABILITY reserves the right to review and report internally and to a 3rd party the results of its review of my application as it deems appropriate. I also give AdaptAbility the right to use my name, medical condition, and photographs for promotional purposes on our website, social media, printed flyers, and any other promotional material we deem necessary if myself is chosen to rent an adaptive bicycle from ADAPTABILITY. By entering your full name in the box below, you are effectively providing your signature, providing your permission to the above and indicating that all the information on this form is true and accurate, to the best of your knowledge. THIS SECTION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN IF APPLICANT IS A MINOR AND/OR CANNOT SIGN. *

Date of Application

MM

DD

YYYY

Applicant's Name

First Name

Last Name

Applicant's Email

Applicant's Phone Number

Country

(###)

###

####

Applicant's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

FULL APPLICATION: all questions marked with an * are required. Answers cannot be saved so make sure to finish and submit the full application at once.

Applicant's date of birth

MM

DD

YYYY

Gender

Applicant's age

Applicant's height (in feet and inches)

Applicant's weight(in pounds)

Please describe Applicant's needs and disabilities.

Number of days Applicant goes to physical therapy (if applicable)

Does the Applicant's physical therapy include the use of a bicycle?

Do you have authorization(s) and recommendation(s) from your doctor and therapist for the use of an adaptive bicycle? If yes, please email any supporting documentation to believe@adaptabilitybike.org

Have you ever rode an adaptive bicycle?

How did you hear about Adapt Ability?

Date

Rental Date

MM

DD

YYYY

Time

Rental Time

Hour

Minute

Second

Rental Time

How long the rental will be for

Helmet

Helmets are required for the rental. Please bring your helmet or do you need a helmet?

Helmet Selection

If you don't have a helmet, please let us know the size you will need

* Environmental Mobility *

Our Goal

Our program developed an environment mobility group that will provide transportation (short distance) to individuals with disabilities.

In simple words we are creating a buddy system that will help individuals with disabilities to ride an adaptive bicycle in short distances to do their everyday activities like errands, appointments and shopping.

Our program will decrease:

the use of cars creating/improving the air (clean/no pollution)
Traffic
transportation expenses
and will increase health benefits to individuals that will never thought will have the option to use a bicycle to commute due to their disabilities.

Why ???

AdaptAbility believes that the improvement of physical health, self-esteem, and independence can be achieved with the use of a bicycle. Now with adaptive bicycles, individuals living with disabilities can experience all the different uses that a bicycle can offer.

AdaptAbility is providing the opportunity to individuals with disabilities to experience this creation and make it part of their life. Individuals with disabilities will take advantage of exercise, while improving their mobility, improving muscle strength, experiencing the outdoors in a completely different way and commuting in short distances all this with the use of an adaptive bicycle.

Our program will be providing an opportunity to remove barriers by increasing different ways of transportation and reducing pollution.

AdaptAbility Free Bicycles for Kids…

Every Child should experience the pleasure of Riding a Bicycle. No child should be deprived of the exposure of mobility, freedom and fun.

AdaptAbility: A Bike For Every Kid FREE…

Adapt Ability would like to thank everyone that helped on our First Christmas Bicycle Drive. Due to the amazing support, we have decided to keep receiving donations. Our new motto will be:

“A bike for every kid”

The more bicycles we can get the more free bicycles for kids.

How the program works:

The program is very simple, if your child or any child that you know is in need of a bicycle please contact us at 718-715-4111 or visit us at our location in Brooklyn, NY.
All bicycles are refurbished bicycles, tuned-up, safe and ready to go.
Sizes available: 12, 16, 20 and 24 inches.
No payment is required but donations are accepted.
Children will need to be accompanied by a parent or legal guardian, to receive a bicycle.
Waiver will need to be signed at the time of pickup and the parent or legal guardian is required to bring a helmet with them(if they do not have a helmet for the child, one can be purchased at our location).
Bicycles will be available until supplies last.

Mobility is medicine for the complete family.

ADAPTABILITY

New programs to help the community

Recycle it

•

Build it

•

Adapt it

•

Recycle it • Build it • Adapt it • Recycle it • Build it • Adapt it •

Applications

AdaptAbility Programs.

AdaptAbility

AdaptAbility Application

AdaptAbility 4Schools

AdaptAbility 4School Application

AdaptAbility 4Ride Kids

AdaptAbility 4Ride Kids Application

AdaptAbility 4Ride Adults

AdaptAbility 4Ride Adult Application

* Environmental Mobility *

Our Goal

Our program developed an environment mobility group that will provide transportation (short distance) to individuals with disabilities.

In simple words we are creating a buddy system that will help individuals with disabilities to ride an adaptive bicycle in short distances to do their everyday activities like errands, appointments and shopping.

Our program will decrease:

the use of cars creating/improving the air (clean/no pollution)

Traffic

transportation expenses

and will increase health benefits to individuals that will never thought will have the option to use a bicycle to commute due to their disabilities.

Why ???

AdaptAbility believes that the improvement of physical health, self-esteem, and independence can be achieved with the use of a bicycle. Now with adaptive bicycles, individuals living with disabilities can experience all the different uses that a bicycle can offer.

Our program will be providing an opportunity to remove barriers by increasing different ways of transportation and reducing pollution.

AdaptAbility Free Bicycles for Kids…

AdaptAbility: A Bike For Every Kid FREE…

“A bike for every kid”

How the program works:

Adapt Ability

Recycle it • Build it • Adapt it •