1. Please complete the following application (all pages) in it’s entirety.
2. Provide the following:
Additional Information
Additional financial verification may be required at a later time to determine eligibility of the applicant.
Photo and News Release:I authorize One Chair at a Time to use photographs and information about my child for promotional and news release purposes.
The athlete will submit a written application to be considered to receive a sport wheelchair from OneChair at a Time, “OCAAT”.Must be minimum age of 7, and maximum age of 19.The sport wheel chair can be taken back by OCAAT if it is not being properly or regularly used.The sport wheelchair must be returned in the same working order as when it was received.The athlete must compete in a sanctioned sporting event in the wheelchair with in six months of receiving it and provide proof of competing.OCAAT will not be held responsible for broken or misused equipment. All maintenance of chairs will be the responsibility of the individual receiving the chair.The Athlete must be physically able to transfer in and out of a sport wheelchair with minimal assistance.The Athlete must provide a physicians release stating that he or she is physically, mentally and emotionally able to compete in competitive sports.The Athlete must attend at least one wheelchair clinic or educational opportunity put on by OCAAT to help the athlete learn to use the sport wheelchair properly and safely.OCAAT will not provide any transportation or compensation to attend or travel to an educational clinic or sporting event. If the Athlete is regularly using the sport wheelchair and out grows it, OCAAT will take the Sport Wheelchair back and replace with a properly fitting new Sport Wheelchair.Assessments for sport wheelchairs to be completed by licensed physical therapists with the assistance of licensed physical therapist assistants provided by OCAAT.
By signing below I certify that I have read, understand, and comply to agree with all rules and regulations ofOne Chair at a Time listed above.