Tracked Wheelchair On-Line Reservation Form

TRACKED WHEELCHAIR RESERVATION FORM

Tracked Wheelchair Reservation Form

* indicates required field

Chair User Full Legal Name:*

If User Under Age 18, list Parent/Guardian full Legal Name:

Address:*

Home Phone #:

Cell Phone #:

E-Mail:

Vehicle License #:*

User's Drivers's License # or State ID #:

User's Auto Insurance Carrier:

Additional Drivers' Legal Name (if applicable)

Additional Drivers' License #:

Additional Drivers Insurance Carrier:

Emergency Contact Phone #:*

Select from one of the following regarding joystick (control) requirements:*

I can only use my right hand and require the joystick on the right.
I can only use my left hand and require the joystick on the left.
I am right handed so prefer a joystick on the right but can use one on the left.
I am left handed so prefer a joystick on the left but can use one on the right.

Preferred Check Out Date:*

Preferred Check Out Time:*

Morning (8-noon)
Afternoon (1 - 5)
Evening (6 - 8)
Other

Preferred Check In Date:*

Preferred Check In Time:*

Morning (8 - noon)
Afternoon (1 - 5)
Evening (6 - 8)
Other

If you have any other questions or concerns please enter them below:

Agreement to Terms:*

Yes

CAPTCHA Code:*