Select your state

VIC	NSW	SA
WA	QLD	TAS
NT	ACT

Who is the equipment for?

Individual

Organisation

Nominated Contact Details

Organisation Name

Role in the Organisation

First Name

Last Name

Mobile

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Client/Rider Contact Details

Is the Client under 18 years of age?

Select "Yes" IF the client is under 18

Select "No" IF the client is above 18

Legal First Name

Legal Last Name

Mobile

Date of Birth

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Address Details

Street Address

Suburb

State

Postcode

Primary Contact Details

Is the Primary Contact same as Client?

Yes

First Name

Last Name

Mobile

Relationship

Organisation

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Community Therapist Details (OT/Physio etc)

First Name

Last Name

Work Phone/Mobile

Work Email

Organisation

Client Details

Diagnosis

Choose all that apply

Intellectual	Physical	Neurological	Vision
Acquired Brain Injury	Hearing	Speech	Psychiatric
Developmental Delay	Autism Spectrum Disorder	Other

Please Specify Other Conditions

Estimated Height

Height

Unit

Estimated Weight

Weight

Unit

Additional Information

Is there any other information you like to include (e.g behavioural

concerns, type of bike you would like to trial)

Upload any additional documentation you would like to include with this request, such as a photo or file.

How did you hear about us?

Recommended by family, health professional, etc	Used the organisation before	Social Media
Internet Search	Blog or publication	Event
Other

Preferred Mode of Communication

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