Applying to My Bike® & My Stroller®

You’ve been invited to apply for an adaptive bike / adaptive stroller! If you have any questions, please don’t hesitate to contact your program manager (or info@varietypittsburgh.org).

For Staff - Online Application (Mobility)

This field is for validation purposes and should be left unchanged.

VARIETY'S MOBILITY APPLICATION

Please Begin By Selecting Your County of Residence in Pennsylvania

PA County Name(Required)

Note, we currently serve 59 counties in Pennsylvania

Child's Information

Which program are you applying for?(Required)

My Bike

My Stroller

How did you hear/learn about Variety's programs?(Required)

^This info. helps us to build a stronger program and ultimately help more kids.

Last Name (Child)(Required)

First Name (Child)(Required)

Diagnosis (es)(Required)

Date of Birth(Required)

Age(Required)

Gender(Required)

Race/Ethnicity:(Required)

Asian/Asian American

Black/African American

Hispanic/Latino/Latina/Latinx

Native American/American Indian/Alaskan Native/Indigenous

White/Caucasian/European

Middle Eastern/Northern African

Native Hawaiian/Pacific Islander

Other

Address(Required)

Street Address Address Line 2 City State ZIP Code

School Child Attends(Required)

School District Child Resides In(Required)

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(Required)

Note - we do not contact insurance. This is for data purposes only.

Secondary Insurance Company

^Put n/a if you don't have secondary insurance.

Home Phone Number(Required)

Cell Phone Number

Work Phone Number

Best Time to Call(Required)

Email Address(Required)

^Email is used to keep you updated on the status of the application, including its approval.

FOR MY BIKE® Program:

Bike Background

Is your child able to ride a traditional two-wheeled bicycle?(Required)

Yes

Unsure

Has your child ever been on a Rifton adaptive bicycle (new or old model)?(Required)

Yes

Unsure

Do you have a safe place at home to store an adaptive bike?(Required)

Yes

Unsure

Are you able to transport an adaptive bike—requiring a mid-large size SUV, Van, or Truck?(Required)

Yes

Unsure

Please briefly tell us about how or where you will use an adaptive bike with your child:(Required)

Has your child received an adaptive bike from Variety?(Required)

Yes

Please note, Variety is limited to providing a maximum of 2 bikes per child over their lifetime.

Is your child currently working with a licensed Physical or Occupational Therapist?(Required)

Yes

Therapist's Name(Required)

Therapist's Organization(Required)

Therapist's Phone Number(Required)

Therapist's Email Address

Child Specifics/Measurements

Child's Height(Required)

Child's Weight(Required)

Maximum Weight Capacity is 310 lbs. as determined by manufacturer.

Child's Inseam Measurement(Required)

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 12“. 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 12 to 22 inches
Medium Bike: Inseam 19 to 28 inches
Large Bike: Inseam 25 to 38 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 fully understand the need and be able to help more kids.(Required)

If re-applying, please tell us how the first bike made an impact - favorite moment or memory?

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 bike would be medically appropriate and therapeutic for the child, and that a conventional bicycle would not be appropriate.

Please click here for specifics on what's required in our My Bike LMJ, as well as an overview of the bike fitting / evaluation.

Additionally, please click here to download the My Bike order form (for those with new Rifton bikes available).

My Stroller® Program

Therapy Background

Is your child an elopement risk (a runner/bolter with lack of safety awareness)?(Required)

Yes

Has your child received an adaptive stroller from Variety?(Required)

Yes

Please note, Variety is limited to providing a maximum of 2 adaptive strollers per child over their lifetime.

Is your child currently working with a licensed Physical or Occupational therapist?(Required)

Yes

Therapist's Name(Required)

Therapist's Organization(Required)

Therapist's Phone Number(Required)

Therapist's Email Address

Child Specifics/Measurements

Child's Height(Required)

Child's Weight(Required)

Maximum Weight Capacity is 250 lbs. (without transit) as determined by manufacturer

Child's Inseam Measurement(Required)

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 better understand the need and be able to help even more kids.(Required)

If re-applying, please briefly tell us how the first stroller made an impact.

MY STROLLER Letter of Medical Justification (LMJ)

Drop files here or

Last Name

First Name

Middle Initial

Gender

Relationship to Child

Date of Birth

Income

Please complete the information below for all persons in your household that have income.

Whose income is this?

Source of income (name of employer, unemployment, social security, etc.)

Variety requires documentation to verify your household income, which includes 1) Yourself, 2) Your spouse, and 3) Anyone that is included as a dependent on your income tax return. Please send a copy of any documents (not the originals). You can also take a clear photo or a screenshot of any income verification and submit it separately to info@varietypittsburgh.org.

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:

Please choose how you want to verify your income:(Required)

Submit Your Most Recent Federal Income Tax Return (preferred)

Submit Verification of Enrollment in SNAP or Free/Reduced Meal

Submit documentation for applicable sources of income for all members of the household

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 showing recipient names, benefits, and a date. This documentation is typically mailed to you, but can also be found through PA’s COMPASS (www.compass.state.pa.us).

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.

OPTION 3: Submit documentation for applicable sources of income for all members of the household:

1) Employed household members 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 any social security number. We cannot accept pay stubs.

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 (valid up to April 15th for the previous year's return), or submit a year-to-date profit and loss statement showing the business name, time frame being reported, gross income received, business related expenses (only) 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. Documentation must show recipient name, date, and monthly amount received.

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.

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 3 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 application approval or disbursement of any equipment, the parent(s)/legal guardian(s) of the Recipient must read and sign this form. Each parent or legal guardian living in the household MUST sign.

I have read and fully understand and agree to the above affirmation of truth, release of liability, and disclaimer.

Furthermore, I acknowledge that Variety can only fund the same piece of equipment twice per child (e.g. 2 bikes, 2 strollers, 2 communication devices).

Parent/Legal Guardian Signature (1):(Required)

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.

BEFORE YOU SUBMIT...

If you need to submit the LMJ or income verification separately, please feel free to email them to info@varietypittsburgh.org. If you need more time, please save your progress and return later. We look forward to hearing from you.