Adaptive / Assistive Equipment Support
Velo Amis support application
Name of Applicant
Best contact email
Best contact phone
City and State where applicant lives
Provide a brief description of need of applicant for adaptive equipment such as bicycle or other device that will be of help.
Does the applicant have specific adaptive equipment that they believe would be of benefit? If so please provide a link or description of equipment.
Is there anything else that you would like Velo Amis to know that would help us evaluate your application?
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