Free Cane Form | Safe Toddles

SAFE TODDLES

nonprofit 501(c)(3)

info@safetoddles.org

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FREE Belt Cane

Request A
Free Pediatric
Belt Cane

We are dedicated to provide a free cane to as many children as possible. Free cane is available to children who become a valuable part of our research study and curriculum. Download the curriculum brief below.

DOWNLOAD SAMPLE OF CURRICULUM

CONTACT INFORMATION

PREFERRED METHOD OF CONTACT

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.

SHIPPING ADDRESS

SHIPPING PREFERENCE

Free Matter for the blind shipping

CHILD'S INFORMATION

CHILD'S MEASUREMENTS

VIEW STANDARD SIZE CHART

Hip width: Inches from hip to hip (ruler)

Waist circumference: Inches around waist (measuring tape, Hip 6)

Waist circumference: Inches around waist (measuring tape, Hip 7)

Waist circumference: Inches around waist (measuring tape, Hip 8)

Waist circumference: Inches around waist (measuring tape, Hip 9)

Height to shoulder: Inches floor to shoulder (Hip 6)

Height to shoulder: Inches floor to shoulder (Hip 7)

Height to shoulder: Inches floor to shoulder (Hip 8)

Height to shoulder: Inches floor to shoulder (Hip 9)

Does child receive any of the following services:

Orientation and Mobility

Physical Therapy

Occupational Therapy

Other

If yes, where have the mobility devices been used?

Home

School

During Therapy Sessions

Other

Download Consent Form

UPLOAD SIGNED CONSENT FORM

Upload File

Upload supported file (Max 15MB)

Thanks for your order!

DONATE

"Every donation gifts toddlers who are blind with a solution for walking safely."

Contact Safe Toddles at info@safetoddles.org or 845-244-6600

Manufactured by Soterix Medical, Inc