Request A Funded Pediatric Belt Cane

Join a project and obtain a fully funded standard pediatric belt cane

We are dedicated to provide a belt cane at no cost to as many children as possible. For children aged 14-56 months funded belt canes and $100 provided to complete the Soterix study. Additional free belt canes can be obtained with the Safe Toddles video project. Older children with mobility visual impairment or blindness can join Safe Toddles project. All belt cane users given access to the belt cane curriculum.

CONTACT INFORMATION

DOWNLOAD SAFE TODDLES CONSENT FORM

DOWNLOAD SOTERIX CONSENT FORM

CONTACT FIRST NAME

CONTACT EMAIL

CONTACT LAST NAME

CONTACT PHONE NUMBER

PREFERRED METHOD OF CONTACT

Email

Text Message

Phone Call

Postage Mail

PHOTO / VIDEO RELEASE. CHECK ALL THAT APPLY

I am 18 years or older

I am an adult signing for a child (younger than 18)

I am an adult signing for myself and a child (younger than 18)

I agree to the terms & conditions of photo/video release. View terms of use.

HOW DID YOU HEAR ABOUT PEDIATRIC BELT CANE?

SHIPPING ADDRESS

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

SHIPPING PREFERENCE

Free Matter for the blind shipping

CHILD'S INFORMATION

Child's First Name

Child's Last Name

Child's Date of Birth (choose the year fist)

Child's Vision Impairment (diagnosis and whether blind, mobility visuly impaired, etc.)

Child's Ethnicity

Describe child's motor/walking skills, list child's motor impairment (e.g., cerebral palsy).

Describe child's learning ability, is the child typically development, developmentally delayed., cognitvely impaired?

CHILD'S MEASUREMENTS

VIEW STANDARD SIZE CHART

Does child receive any of the following services:

Orientation and Mobility

Physical Therapy

Occupational Therapy

Other

List the mobility tools/devices used to date (if applicable)

If yes, where have the mobility devices been used?

Home

School

During Therapy Sessions

Other

When alone, child most likely will?

Why do you want a wearable cane?

Have you requested a cane before?

Tell us if you need a custom size.

Complete all fields to Submit the form, including uploading Consent Form for the study you have selected.

Thanks for your order!