Variety’s Online Program Application

To save your progress and continue the application later, please scroll to the bottom and click "Save Progress and Continue Later" in the red box. If you need an application mailed to you, please contact us at info@varietypittsburgh.org or at (724) 933-0460.
Child's Information
How did you hear/learn about Variety's programs?*
^This info. helps us to build a stronger program and ultimately help more kids.
Last Name (Child)*
First Name (Child)*
Middle Initial (Child)
Diagnosis (es)*
Date of Birth*
MM slash DD slash YYYY
Age*
Gender*
Address*
Street Address Address Line 2 City State ZIP Code
County Name*
School Child Attends*
School District Child Resides In*
Any Union Affiliation?

^It is helpful to know if if anyone in your family is a member of a local union, as we have close partnerships with unions.
Primary Insurance Company*
Secondary Insurance Company*

^Put n/a if you don't have secondary insurance.
Home Phone Number*
Cell Phone Number
Work Phone Number
Best Time to Call*
Email Address

^E-mail is used to update you on the status of the application and approvals.
Which program(s) are you applying for?*
- My Stroller
- My Voice
^Note that you can apply for both programs.
FOR MY BIKE® Program:
Bike Background
Is your child able to ride a traditional two-wheeled bicycle?*
- Yes
- No
- Unsure
Has your child ever been on a Rifton adaptive bicycle?*
- Yes
- No
- Unsure
Is your child currently working with a licensed Physical or Occupational therapist?*
- Yes
- No
Therapist's Name*
Therapist's Organization*
Therapist's Phone Number*
Therapist's Email Address
Child Specifics/Measurements
Child's Height*
Child's Weight*

Maximum Weight Capacity is 200 lbs. as determined by manufacturer
Child's Inseam Measurement*

^Must include inseam measurement to be processed.
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 describe how an ADAPTIVE BIKE will impact your child and whole family. What is your hope with this equipment? Anything you can share will be vital to helping us better understand the need and help more kids.*
If re-applying, please briefly tell us how the first piece of equipment made an impact.
MY BIKE Letter of Medical Justification (LMJ)
Drop files here or

Max. file size: 256 MB.
The My Bike LMJ must be completed by a licensed Physical/Occupational Therapist, Personal Care Physician, Physician Assistant, or Nurse Practitioner, who indicates 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.
My Voice® Program
Our My Voice® Program is financed {in part} by a grant from the Commonwealth of Pennsylvania, Department of Community and Economic Development as well as generously funded by community donations.
Speech Therapy Background
Has your child ever had a speech and language evaluation?*
- Yes
- No
- Unsure
Does your child currently use a communication device at SCHOOL?*
- Yes
- No
- Unsure
Does your child currently use a communication device in THERAPY?*
- Yes
- No
- Unsure
Does your child currently work with a licensed Speech Language Pathologist (SLP)?*
- Yes
- No
- Unsure
SLP's Name*
SLP's Organization*
SLP's Phone Number*
SLP's Email Address
Please describe how a COMMUNICATION DEVICE will impact your child and whole family. What is your hope with this device? Anything you can share will be vital to helping us better understand the need and help more kids.*
If re-applying, please briefly tell us how the first piece of equipment made an impact.
MY VOICE Letter of Medical Justification (LMJ)
Drop files here or

Max. file size: 256 MB.
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.
My Stroller® Program
Therapy Background
Is your child currently working with a licensed Physical or Occupational therapist?*
- Yes
- No
Therapist's Name*
Therapist's Organization*
Therapist's Phone Number*
Therapist's Email Address
Child Specifics/Measurements
Child's Height*
Child's Weight*

Maximum Weight Capacity is 200 lbs. as determined by manufacturer
Child's Inseam Measurement*
Please measure the child’s inseam from the groin to the bottom of the foot (with shoes on).
Please describe how an ADAPTIVE STROLLER will impact your child and whole family. What is your hope with this equipment? Anything you can share will be vital to helping us better understand the need and help more kids.*
If re-applying, please briefly tell us how the first piece of equipment made an impact.
MY STROLLER Letter of Medical Justification (LMJ)
Drop files here or

Max. file size: 256 MB.
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.
Household Members
Please list all the people who live in your household, including the child applying. Start with yourself.
How many members live in your household?*
Household Member #1
Last Name*
First Name*
Middle Initial
Relationship to Child*
Gender*
Date of Birth*
MM slash DD slash YYYY
Household Member #2
Last Name*
First Name*
Middle Initial
Relationship to Child*
Gender*
Date of Birth*
MM slash DD slash YYYY
Household Member #3
Last Name*
First Name*
Middle Initial
Relationship to Child*
Gender*
Date of Birth*
MM slash DD slash YYYY
Household Member #4
Last Name*
First Name*
Middle Initial
Relationship to Child*
Gender*
Date of Birth*
MM slash DD slash YYYY
Household Member #5
Last Name*
First Name*
Middle Initial
Relationship to Child*
Gender*
Date of Birth*
MM slash DD slash YYYY
Household Member #6
Last Name*
First Name*
Middle Initial
Relationship to Child*
Gender*
Date of Birth*
MM slash DD slash YYYY
Household Member #7
Last Name*
First Name*
Middle Initial
Relationship to Child*
Gender*
Date of Birth*
MM slash DD slash YYYY
Household Member #8
Last Name*
First Name*
Middle Initial
Gender*
Relationship to Child*
Date of Birth*
MM slash DD slash YYYY
Household Member #9
Last Name
First Name
Middle Initial
Gender
Relationship to Child
Date of Birth
MM slash DD slash YYYY
Household Member #10
Last Name
First Name
Middle Initial
Gender
Relationship to Child
Date of Birth
MM slash DD slash YYYY
Income
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.
CHOOSE ONLY ONE OPTION to verify your household income:
OPTION 1: Submit Your Most Recent Federal Income Tax Return:
If you filed a federal income tax return, then you can submit your most recent Form 1040 with all related schedules (valid up to April 15th for the previous year’s return). Please black out social security number(s).
Drop files here or

Max. file size: 256 MB.
OPTION 2: Submit Verification of Enrollment in One of These Programs:
1) Supplemental Nutrition Assistance Program (SNAP): If your household is enrolled in SNAP, then submit proof of enrollment (e.g. documentation of enrollment for the current year).
Drop files here or

Max. file size: 256 MB.
2) Free/Reduced Meal Program: If a child in your household is enrolled in the free/reduced meal program, then request documentation from your child’s school and submit to Variety to verify income eligibility.
Drop files here or

Max. file size: 256 MB.
If choosing Option 2 for income verification, please also list your total household income (below).
What is the total monthly income for your household (approximately)?
OPTION 3: Submit documentation for one of the choices below:
1) If a household member is employed: Submit TWO pay stubs from the last 60 days. Send more pay stubs if pay changes regularly, or if pay stubs cannot be obtained, please contact Variety.
In place of pay stubs, an employed household member can submit their most recent W-2 to verify income (valid up to April 15th for the previous year’s W-2). Please black out social security number.
Drop files here or

Max. file size: 256 MB.
2) If a household member is self employed: Include the most recent federal income tax return and all related tax schedules and forms, or submit a year-to-date profit and loss statement showing the business name, time frame being reported, gross income received, only business related expenses by line item, and the net profit. Please sign and date.
Drop files here or

Max. file size: 256 MB.
3) If a household member is a seasonal or temporary employee: Include the most recent federal income tax return and all related tax schedules and forms.
Drop files here or

Max. file size: 256 MB.
4) If a household member receives Unemployment Compensation: Submit the Notice of Financial Determination award letter or check stubs.
Drop files here or

Max. file size: 256 MB.
5) If a household member receives Social Security, Survivor’s or Disability Benefits, Retirement, Pension, or Worker’s Compensation: Submit the most recent award letter, a Form 1099, or a bank statement which shows the direct deposits to a bank account.
Drop files here or

Max. file size: 256 MB.
6) If a household member receives child support or alimony: Submit the support order or a copy of the payment history for the past 12 months. This can be obtained through the state child support enforcement agency or bureau.
Drop files here or

Max. file size: 256 MB.
If choosing Option 3 for income verification, please complete the information below for all persons in your household that have income.
How many members in your family have income?
Household Member #1:
Whose income is this?
Source of income (e.g. name of employer, unemployment, social security, etc.)
Household Member #2:
Whose income is this?
Source of income (name of employer, unemployment, social security, etc.)
Household Member #3:
Whose income is this?
Source of income (name of employer, unemployment, social security, etc.)
Household Member #4:
Whose income is this?
Source of income (name of employer, unemployment, social security, etc.)
Household Member #5:
Whose income is this?
Source of income (name of employer, unemployment, social security, etc.)
Household Member #6:
Whose income is this?
Source of income (name of employer, unemployment, social security, etc.)
Household Member #7:
Whose income is this?
Source of income (name of employer, unemployment, social security, etc.)
Household Member #8:
Whose income is this?
Source of income (name of employer, unemployment, social security, etc.)
Household Member #9:
Whose income is this?
Source of income (name of employer, unemployment, social security, etc.)
Household Member #10:
Whose income is this?
Source of income (name of employer, unemployment, social security, etc.)
What is the total income for your household (approximately)?
Required Signature
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:
- Any alleged malfunction of or defect in the enabling equipment;
- Any allegation that the enabling equipment was not appropriate or suitable for the Recipient.
- Any other matter, of any type, related, in any way, to the Recipient’s receipt or use of the enabling equipment.
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.
Parent/Legal Guardian Signature (1):*

Enter your full name as your signature.
Parent/Legal Guardian Signature (2):

Enter your full name as your signature.
Media Release Form
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.
Parent/Legal Guardian Signature (1):

Enter your full name as your signature.
Parent/Legal Guardian Signature (2):

Enter your full name as your signature.
Name
This field is for validation purposes and should be left unchanged.

Save Progress and Continue Later

Variety’s Online Program Application

Child's Information

FOR MY BIKE® Program:

Bike Background

Child Specifics/Measurements

My Voice® Program

Speech Therapy Background

My Stroller® Program

Therapy Background

Child Specifics/Measurements

Household Members

Household Member #1

Household Member #2

Household Member #3

Household Member #4

Household Member #5

Household Member #6

Household Member #7

Household Member #8

Household Member #9

Household Member #10

Income

CHOOSE ONLY ONE OPTION to verify your household income:

Household Member #1:

Household Member #2:

Household Member #3:

Household Member #4:

Household Member #5:

Household Member #6:

Household Member #7:

Household Member #8:

Household Member #9:

Household Member #10:

Required Signature

Media Release Form