MI Kids On The Move Program Equipment Request Form
This application is for programs serving children with limited mobility who are seeking equipment to use with children in their program. If you are looking for an appication for your child please fill out the child application on our website or facebook page. Once funding is secured for a presentation we will set up an event to present our program to the programs and give them their equipment. We hope to achieve this right after the new year if we can demonstrate that we have a response for this presentation.
Terms of Service
MI Kids On The Move will provide equipment to programs as resources are acquired. An application does not gaurantee your program will recieve the equipment requested.
Name of program requesting equipment
City, School District, County
Name and title of Person filling out request form
Age range of children in the program
Equipment requested -you can request more then one piece of equipment for your program as long as children within your program are within the age range.
Modified ride on toy 6 volt
Modified ride on toy 12 volt
Mini wheel chair
Please list your preference for equipment for equipment. If resources allow you can receive more then one piece of equipment. If not you will be given your first choice and put on a waiting list for the other equipment as resources allow.
By submitting the MI Kids On The Move Program Equipment Request Form, I certify that I have read and understood the Terms of Service above and I agree to be bound by its terms.
Printed Signature (Print first and last name)
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Terms of Service