Please measure the child’s inseam from the groin to the bottom of the foot (with shoes on). Minimum inseam length for a small sized bike is 17“. This length safely ensures the extended leg can reach from seat to pedal comfortably when both feet and torso are strapped into place.
Small Bike: Inseam 17 to 22 inches
Medium Bike: Inseam 22 to 28 inches
Large Bike: Inseam 25 to 35 inches
Please click here for more specifics on our My Bike LMJ and the bike fitting / evaluation.
Please click here for the My Bike Order Form if Rifton adaptive bikes are available.
My Voice LMJ: The My Voice LMJ must be completed by a licensed Speech Language Pathologist (preferably with ASHA Certification) who also completed an evaluation of the child using an iPad, and can then provide a recommendation for the appropriate communication application that successfully works for the child.
Please click here for more specifics on the LMJ.
Please measure the child’s inseam from the groin to the bottom of the foot (with shoes on).
My Stroller LMJ: The My Stroller LMJ should be completed by a licensed Physical/Occupational Therapist, Personal Care Physician, Physician Assistant, or Nurse Practitioner indicating and detailing that the Convaid EZ Rider adaptive stroller would be medically appropriate and therapeutic for the child.
Please click here for more specifics on the LMJ.
Additionally, the same professional should complete our My Stroller Measurement Sheet, which can be downloaded by clicking here.
Please list all the people who live in your household, including the child applying. Start with yourself.
As part of the program application, Variety requires documentation to verify your household income, which includes - 1) Yourself, 2) Your spouse (if you are married), and 3) Anyone that is included as a dependent on your income tax return.
As an example, income can include, but is not limited to: Wages, salaries, tips, bonuses; commissions, etc.; Interest; Dividends; Taxable refunds, credits, or offsets of state and local income taxes; Self-employment net profit/loss; Capital/other gain or loss; IRA distributions; Pensions and annuities; Rental real estate, royalties, trusts, & REMIC; Alimony received; Farm income/loss; Unemployment Compensation; Worker’s Compensation; Social Security benefits; or any other income being received.
OPTION 1: Submit Your Most Recent Federal Income Tax Return:
OPTION 2: Submit Verification of Enrollment in One of These Programs:
If choosing Option 2 for income verification, please also list your total household income (below).
OPTION 3: Submit documentation for one of the choices below:
If choosing Option 3 for income verification, please complete the information below for all persons in your household that have income.
Affirmation of Truth: I (We) stipulate that the information included in this application is true to the best of my (our) knowledge. Further, I (we) understand that the presence of inaccurate information in this application could result in the need for the re-evaluation of this application on the part of Variety—the Children's Charity.
Release of Liability: In consideration of the receipt of certain enabling equipment awarded by Variety — the Children's Charity, the recipient thereof, him /herself or through his/her parent or legal guardian, hereby releases and forever discharges Variety—the Children's Charity of Pittsburgh, Variety—the Children's Charity International, and Variety—the Children's Charity of the United States, their members, employees and officers (hereafter collectively referred to as “Variety”) from and against any and all claims, of any type, which arise from or are related to:
Disclaimer: Variety—the Children’s Charity strives to provide adaptive equipment that is individually customized for eligible children ages of 4 through 21. The equipment we provide carries no warranty from Variety and its use, even in the event of malfunction resulting in injury, gives rise to no liability on the part of Variety. Variety is merely a funding source. Variety is in no way responsible for maintaining or repairing any equipment. It is the sole responsibility of the Recipient's parent(s)/legal guardian(s) to maintain, and /or repair. Any other costs that may be associated with the equipment such as installation, delivery, labor, disposal, etc. that are not explicitly stated on the application are the sole responsibility of the Recipient's parent(s)/legal guardian(s). Before disbursement of any equipment, the parent(s)/legal guardian(s) of the Recipient must have this form signed. Each parent or legal guardian living in the household MUST sign.
Should the equipment no longer be needed (or outgrown), Variety requests that the parent(s)/legal guardian(s) contact Variety for equipment to be returned.
I have read and fully understand and agree to the above affirmation of truth, release of liability, and disclaimer.
The Recipient and his/her parents or legal guardians hereby acknowledge and agree that acceptance of the enabling equipment from Variety—the Children’s Charity may result in publicity. The Recipient and his/her parents or legal guardians hereby irrevocably authorize Variety: (a) to publicize and use the Recipient's likeness, voice and features, with or without his/her name, for any publication, promotion, trade or business use, or any other purpose; (b) to photograph, videotape, film and record each Recipient in any manner Variety chooses; (c) to copyright, convey or otherwise distribute, now or in the future, any such material involving the Recipient, his/her parents or legal guardian and that said material may be distributed to anyone, for any purpose, including the general public, magazines, newspapers, television, radio stations; (d) to publicize, now or in the future, the name of the Recipient including information regarding his/her physical condition and details regarding the enabling equipment received from Variety. The Recipient and his/her parents or legal guardians agrees that it is not necessary for Variety or anyone else to contact them prior to releasing any information authorized by this document. The Recipient and his/her parents or legal guardians hereby releases Variety from and against any and all claims, of any type, which arise from or are related to Variety's use, distribution or disclosure of any photographs, films, videotapes, electronic recording or other information regarding the Recipient and the award from Variety.
Any media that Variety can share will greatly help our efforts to secure future funding, and to help even more kids. Please note that we will only publish media (e.g. photos/videos) of children authorized by families that signed this release form. Other photos will be kept confidential.