Please measure the child’s inseam from the groin to the bottom of the foot (with shoes on). The extended leg should 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
"My Bike” LMJ: Submit a Letter of Medical Justification (LMJ) from a licensed Physical / Occupational Therapist or a Personal Care Physician indicating that a Rifton adaptive bicycle would be medically appropriate and therapeutic for the child, and that a conventional bicycle would not be appropriate.
Please click here for more specifics on our “My Bike” LMJ and the bike fitting / evaluation.
Additionally, if you need a “My Bike” Order Form, please click here.
“My Voice” LMJ: The letter of medical justification (LMJ) must be completed by a licensed Speech Language Pathologist (SLP) 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, which has been trialed by the SLP with the child. If a licensed SLP is writing the LMJ, but does not have ASHA Certification, then he/she can have their ASHA Certified Supervisor sign off on the LMJ that’s being prepared for the child and submitted to Variety.
Please click here for more specifics on the LMJ.
“My Stroller” LMJ: Submit a Letter of Medical Justification (LMJ) from a licensed Physical / Occupational Therapist or Personal Care Physician indicating and detailing that the Kid Kart® Mighty Lite 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” Order Form & Measurement Sheet, which can be downloaded by clicking here.
Please list all the people who live in your household. Start with yourself.
As part of the program application, Variety requires income verification for your family’s household, which includes: Yourself, Your spouse (if you are married), and Anyone that is included as a dependent on your income tax return.
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 the Programs Below:
For the free/reduced meal program (only), your household must also meet our program’s income guidelines, and you must provide your total household income (below).
Option 3: Submit All Options that apply for all persons in your household that have income:
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.
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.
Please note that your signature is not required on this form for the application to be considered by Variety—the Children's Charity. However, we do require photos of your child with their awarded equipment. Please note that we will only publish photos of children authorized by families signing this release form. Other photos will be kept confidential. All photos enhance our fundraising efforts to secure additional funding from corporate sponsors, individuals, and community foundations to help children with disabilities and to continue our programs. Thank you.