Amtryke Therapeutic Form PDF Details

There are many therapeutic forms that can help improve a person's physical and cognitive abilities. One such form is the Amtryke therapeutic form. Amtrykes are specially designed tricycles that can be adjusted to fit the needs of each individual rider. They provide exercise and therapy for people with disabilities, helping them to strengthen their muscles and improve their coordination. Amtrykes come in a variety of shapes and sizes, making them perfect for people of all ages and abilities. If you're looking for a way to improve your loved one's physical abilities, an Amtryke might be the perfect solution!

Question	Answer
Form Name	Amtryke Therapeutic Form
Form Length	13 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 15 sec
Other names	ambucs request online, amtryke therapeutic, ambucs amtryke form, amtryke request online

Form Preview Example

Amtryke Therapeutic Tricycle Request Form

(Must be filled out completely by adult rider or parent/guardian)

Recipie t’s Na e:	Age:		Date of Request:
Mailing Address:			Phone #:
City/State/Zip:		Email:

Diagnosis:

If Recipient is Under Age 18

Parent/Guardian Name:

If different from above

Mailing Address:

Phone #:

City/State/Zip:

Email:

Secondary Contact Name:

Phone #:

Treati g Therapist’s Na

Phone #:

Email:

How did you hear about the Amtryke Therapeutic Tricycle? (Check all that apply)

□ Therapist □ Website

□ AMBUCS Member □ Other:

Will you need financial assistance to obtain the tricycle?

□ Yes

□ No

If yes, how much can you pay?

Note: Amtryke therapeutic tricycles are distributed based on available funds and need. Individual placements of Amtryke therapeutic tricycles are at the discretion of the local chapter or parent organization.

Tell us about the recipient*:

*This information will be made public to help obtain funding. Please don’t include information you do ’t want shared.

Including a photo of the recipient will help us obtain funding to help pay for the Amtryke more quickly. Digital images preferred but we also accept professionally printed glossy photos. No photocopies or folded images.

By including a photo, you are giving consent for AMBUCS to use the image online and in print to help obtain funding.

Signature:

Date:

Individuals will not be considered for placement until all three forms are returned to AMBUCS: this form filled out by the recipient/guardian, as well as the Assessment Form and Tryke Selection Form filled out by the therapist.

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center	(800) 838-1845
Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org
This Form, the Assessment Form and Tryke Selection Form must be received by your local chapter or the Resource Center before placement is considered.

Amtryke Therapeutic Tricycle Waiver Form

(Must be filled out completely by adult rider or parent/guardian)

AMBUCS members nationwide are dedicated to creating opportunities for mobility and independence for people with disabilities by providing AmTryke therapeutic tricycles, offering educational scholarships to therapy students and performing various forms of community service.

Purpose: The AmTryke therapeutic tricycle is designed for people with disabilities. It creates a feeling of freedom, builds self-esteem, strengthens muscles and improves motor coordination and rage of motion—all while making exercise fun.

Steering: Initially, the rider may have difficulty turning or changing directions. Encourage the rider to go straight ahead, back up and slowly turn around. On many models there are three steering options for the Amtryke. On the front column of the tricycle you will find two holes for the steering pin. The top hole is straight steering, the bottom hole allows a 20 degree turning radius. Leaving the pin out gives the rider free steering.

Safety Cautions

•Fast speeds and sharp turns can cause the Amtryke therapeutic tricycle to tip or turn over.

•Always wear a helmet when riding an Amtryke. Use of other protective gear is highly recommended.

•Adult supervision required if used by younger or developmentally delayed riders.

•Use caution near vehicles, swimming pools and other bodies of water, hills, alleys and sloped driveways.

•Always wear shoes.

•Never allow more than one rider.

•Use of the steering pin is recommended to prevent over-steering and possible tip-overs.

The information contained in this document is not intended nor implied by National AMBUCSTM, Inc. to be professional medical advice by National AMBUCS, Inc. Always seek the advice of your physician, therapist or other qualified healthcare provider prior to staring any treatment or with any question you may have regarding a medical condition. Nothing contained in this document is intended by National AMBUCS, Inc. to be for medical diagnosis or treatment by National AMBUCS, Inc. or on behalf of National AMBUCS, Inc.

In no event shall National AMBUCS, Inc. be liable for any direct, indirect, incidental, consequential, special, exemplary, punitive, or any other monetary or other damages, personal injury or property damages, fees, fines, costs, attorney fees, or liabilities of any kind arising out of or relating in any way to this service or use of the Amtryke® therapeutic tricycle, and/or content or information provided herein.

I agree that I may be photographed by National AMBUCS. I also agree that my photo and name may be used in promotional efforts for National AMBUCS and Amtryke, LLC. I further grant National AMBUCS the ability to use the photos and name for advertising/publicity purposes without additional compensation, except where prohibited by law.

By signing below, I acknowledge that I have read and understood this liability waiver.

Recipie t’s Na e (printed):

Adult Recipient Signature:

If Recipient is Under Age 18

Legal Guardian Name:

Legal Guardian Signature:

Date:

Individuals will not be considered for placement until all three forms are returned to AMBUCS: this Form filled out by the recipient/guardian, as well as the Assessment Form and Tryke Selection Form filled out by the therapist.

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center	(800) 838-1845
Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org
This Form, the Assessment Form and Tryke Selection Form must be received by your local chapter or the Resource Center before placement is considered.

Amtryke Assessment Form

(Must be filled out completely by therapist)

‘e ipie t s Na e:

Age:		Weight (lbs.):*	Height (inches):*

Diagnosis(es):*
	*This private information is only used to help appropriately fit the rider.

RIDER’S MEASUREMENTS

Center of Shoulder

Center of Elbow

Arm Measurements (inches)

Total Length

Center of Digit Crease

Left

A to B:

B to C:

Center of Hip

Right

A to B:

B to C:

Center of Knee

Trunk

A to D:

Bottom of Foot

Leg Measurements (inches)

Total Length

Arm Length & Leg

Left

D to E:

E to F:

Length Measurements

Right

D to E:

E to F:

are critical to correct

Amtryke Selection

Notes on Provided Measurements (if any):

Helmet Sizing

Sizing Chart is

Size

Measurement (head circumference)

available online:

XXS

. ” to

. ”

www.ambucs.org/riders

. ” to

”

/wish-list/sizing-chart/

S/M

” to

. ”

L/XL

. ” to

. ”

Therapist Name:

Is this the treating therapist?

□ Yes

□ No

Credentials:

Phone:

Email:

Facility Name:

Street Address:

City:

State:

Zip:

Is this facility an Amtryke Evaluation Site?

□ Yes

□ No □ Not Sure

Therapist comments concerning recipient or goals:

This request/assessment is directed to:

□Local AMBUCS Chapter Name:

□National Wish List (AMBUCS Resource Center)

By signing below, you are signifying that in your professional opinion this rider would benefit from an Amtryke. You assume no liability.

Therapist Signature:Date:

Ship Amtryke To

Name/Facility:	Phone:

Street Address:

City:	State:	Zip:
Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center		(800) 838-1845
Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830		ambucs.org

This Form, Tryke Selection Form and the Request/Liability Waiver Form must be received by your local chapter or the Resource Center before placement is considered.

Recipie t’s Na e:

Thanks for choosing an Amtryke therapeutic tricycle!

In order to accommodate the widest variety of people and disabilities, Amtryke offers many tryke models and each can be customized in a variety of ways. Following the steps below will help you choose to the perfect tryke for your client from what might seem like a dizzying array of options.

Remember you can always refer to our website, www.amtrykestore.com, or the Amtryke catalogue for more information and product images.

Step 1: Fill out the first page of the Amtryke Assessment Form.

Step 2: Choose the way the tryke will be propelled: Hand & Foot, Foot, or Hand. Your hoi e should be based o the rider s ability and therapy goals.

Hand & Foot trykes improve coordination, strength and range of motion. Using all four extremities helps with weakness in any area, even general weakness, and can positively affect tone.

Foot trykes were developed in response to requests from therapists for a traditional tricycle for riders with special needs.

Hand trykes are designed for persons whose lower limbs lack function or those who need special therapy for the upper extremity.

Step 3: Take rider s	easure e	ts fro	the front of this Assessment Form and compare them to our Sizing Chart.
(This will narrow the choices considerably)
Step 4: Choose a dri	e. (If it does	t	e tio a hoi e, the ig ore this step.

Amtrykes come with two drive possibilities: fixed drive or geared drive. Tryke models have been carefully designed so the drive matches the therapeutic goals of the equipment; therefore all drives are not available on all trykes.

A fixed drive, o o l k ow as a fixie, works on a mechanical level to help individuals make a full pedal rotation. The foot crank is constantly in motion for full therapeutic effect. Coasting is not possible with a positive drive; when limb motion stops, the bike does as well.

Riders of geared drive trykes must be able to make a complete pedal rotation on their own. This tryke is suitable for riders who need help with balance and a stable sitting position and who have the cognitive ability to steer successfully and apply the coaster brake or hand brake. The key feature of geared trykes is the ability to coast.

Step 5: Chose any adaptations and/or accessories needed by the rider. Each tryke model can only be customized in the ways noted in its own model section in the Tryke Selection Forms or with the generic accessories listed below. If a customization option is not listed, it is because of design or other practical constraints in offering it on a particular model.

GENERIC ACCESSORIES (not model specific)

Safety Items	□	Safety Flag	□ NEW! Medical Cart			□ Water Bottle w Cage			□ License Plate
			(carries 02 bottle/ventilator/tubing)
Leg & Foot Items	□	Foot Cups (pair):	□	Knee Adductor Strap:		□	Pedal Block ( = ¾”		_____qty
	□	Small	□	Small	□ Large
	□	Medium	□	Medium

Hand Items	□ Variable Range of		□	Wrist Wraps		□	Wrist Brace Mitt:
	Motion Kit		(Includes right & left)			□ Right		□ Left
	Motion Kit					□ Right		□ Left
	(only for Hand & Foot Cycles)		□ X-Small		□ Large	□	XX-Small	□ Medium
			□ X-Small		□ Large	□	XX-Small	□ Medium
			□ Small			□	X-Small
			□ Medium			□ Small

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center	(800) 838-1845
Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org

This Form, Tryke Selection Form and the Request/Liability Waiver Form must be received by your local chapter or the Resource Center before placement is considered.

Recipie t’s Na e:

FOOT TRYKES

□New! 1410 FOOT TRYKE – (with 11” wheels, fixed drive) 50-FC-0100 Arm Length 7-20”, Leg Length 14-21”

□Option #1 – Standard Seating System: Blue Bucket Seat

□Option #2 – Upgraded Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion*		□ Notched Wide Bottom Cushion*	□ XL Seat Back
	□ Laterals	□ H-Harness: □ ” □ . ” *Cannot be used with rear steering
1410 Accessories:	□ Rear Steering Kit	□ Pull/Steering Bar
	□ Push Bar	□ Heavy-Duty Push Bar

□ SNAPPY FOOT TRYKE (with ” wheels, fixed drive) – 50-FC-0150 Arm Length 9-13”, Leg Length 17-22”

□Option #1 – Standard Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion □ Notched Wide Bottom Cushion □ XL Seat Back

□ Laterals

□ H-Harness: □ ” □ . ”

□Option #2 – Alternate Seating System: Blue Bucket Seat

□Option #3 – Alternate Seating System: Saddle Seat/Gray Plastic Back/Seat Post

Snappy Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Exercise Pedals

□1412 ProSeries FOOT TRYKE (with ” wheels, fixed drive) – 50-FC-1412 Arm Length 14-22”, Leg Length 21-26”

□Option #1 – Standard Seating System: Saddle Seat/1600 Simple Seat Back

Seat Bottom Alternates:	□ Pommel Saddle Seat □ Mediu			(11.5x10	”	)	□ Skinny Saddle Seat ( . x ”

Trunk Support Upgrades:				□ ProSeries Head Rest □ ProSeries Full Padded Back
	□ ProSeries Seatback
		backpad & 2 laterals)
	(includes push grip,		↴	□ ProSeries Back Spacer Kit
	□ ProSeries Lumbar Pad
	□ H-Harness: □ ” □		. ”	□ AM Full Padded Back

□Option #2 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories:	□ H-Harness:	□ ” □ . ”

□Option #3 – Upgraded Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion □ Notched Wide Bottom Cushion □ XL Seat Back

	□ Laterals		□ H-Harness: □ ” □ . ”
1412 Accessories:	□ Pull/Steering Bar	□ Push Bar		□ Heavy-Duty Push Bar	□ Knee Separator: □ ” □ ”
	□ Toe Pedal Leveler Pulley			□ Hand Brake	□ Exercise Pedals
	□ Hi-Rise Handlebars: □ ” (BMX		□	”

□Rear Steering Kit (NEW! Takes the place of 1500 Series)

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center	(800) 838-1845
Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org

This form, the Assessment Form and the Request/Waiver From must be received by your local chapter or the Resource Center before placement is considered.

Recipie t’s Na e:

□ 1416 ProSeries FOOT TRYKE (with

” wheels, fixed drive) – 50-FC-1416 Arm Length 14-22”, Leg Length 24-32”

□ Option #1 – Standard Seating System: Saddle Seat with ProSeries Seatback System (Includes push grip, backpad & 2

laterals)

Seat Bottom Alternates:

Bench Seat

Padded Tractor Seat with bracket

Pommel Saddle Seat

Trunk Support Upgrades:

□

□ ProSeries Full Padded Back

□

□ Med (11.5x10”) □ Large↴(

”)

□ ProSeries Head Rest

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ” □ Recumbent 10 Degree Seat Post

□ Option #2 – Upgraded Seating System: Saddle Seat/1600 Simple Seat Back

”

□ Large

”

Seat Bottom Alternates:

□ Padded Tractor Seat with bracket

□ Pommel Saddle Seat □ Mediu

(11.5x10

)

(

)

Trunk Support Upgrades:

□ H-Harness: □ ” □

. ”

□ ProSeries Lumbar Pad

□ Option #3 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories: □ H-Harness: □ ” □

. ”

1416 Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Knee Separator: □

” □

”

□ Calf & Leg Support

□ Toe Pedal Leveler Pulley

□ ” exte der tube

□ Hi-Rise Handlebars: □

” □

”

□ Exercise Pedals

□ Rear Steering Kit (NEW! Takes the place of 1500 Series)

□ 1420 ProSeries FOOT TRYKE (with

” wheels, fixed drive) – 50-FC-1420 Arm Length 18-28”, Leg Length 27-35”

□ Option #1 – Standard Seating System: Saddle Seat with ProSeries Seatback System (Includes push grip, backpad & 2

laterals)

Seat Bottom Alternates:

Bench Seat

Padded Tractor Seat with bracket

Pommel Saddle Seat

Trunk Support Upgrades:

□

□ Med (11.5x10”) □ Large↴(

”)

□ ProSeries Head Rest

□ ProSeries Full Padded Back

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ”

□ Recumbent 10 Degree Seat Post

□ Option #2 – Upgraded Seating System: Saddle Seat/1600 Simple Seat Back

”

□ Large

”

Seat Bottom Alternates:

□ Padded Tractor Seat with bracket

□ Pommel Saddle Seat □ Mediu

(11.5x10

)

(

)

Trunk Support Upgrades:

□ H-Harness: □ ” □

. ”

□ ProSeries Lumbar Pad

□ Option #3 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories: □ H-Harness: □ ” □

. ”

1420 Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Knee Separator: □

” □

”

□ Toe Pedal Leveler Pulley

□ Calf & Leg Support

□ Hi-Rise Handle Bars: □ ” □

”

□Rear Steering Kit (NEW! Takes the place of 1500 Series)

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center	(800) 838-1845
Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org

This form, the Assessment Form and the Request/Waiver From must be received by your local chapter or the Resource Center before placement is considered.

Recipie t’s Na e:

NOW AVAILABLE!

□NEW! 1420XL ProSeries FOOT TRYKE (with ” wheels, fixed drive) – 50-FC-1420-XL Arm Length 20-32”, Leg Length

28-43”

□Option #1 – Standard Seating System: Saddle Seat with ProSeries Seatback System (Includes push grip, backpad & 2

laterals)

Seat Bottom Alternates:					Pommel Saddle Seat
Trunk Support Upgrades:	□ Bench Seat	□ Padded Tractor Seat with bracket		□	□ Med (11.5x10”) □ Large↴( x ”)
	□ ProSeries Head Rest		□ ProSeries Full Padded Back		□ ProSeries Lumbar Pad
	□ H-Harness: □ ” □	. ”	□ Recumbent 10 Degree Seat Post

□Option #2 – Upgraded Seating System: Saddle Seat/1600 Simple Seat Back

Seat Bottom Alternates:	□ Padded Tractor Seat with bracket	□ Pommel Saddle Seat □ Mediu		”	□ Large		x	”
Seat Bottom Alternates:			(11.5x10	)		(		)
Trunk Support Upgrades:		□ H-Harness: □ ” □ . ”
	□ ProSeries Lumbar Pad	□ H-Harness: □ ” □ . ”

□Option #3 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories:	□ H-Harness: □ ” □	. ”
1420 Accessories:	□ Pull/Steering Bar	□ Push Bar	□ Heavy-Duty Push Bar		□ Knee Separator: □ ” □	”
	□ Toe Pedal Leveler Pulley		□ Calf & Leg Support	□ Hi-Rise Handle Bars: □ ” □		”

□Rear Steering Kit (NEW! Takes the place of 1500 Series)

□1616 ProSeries FOOT TRYKE (with ” wheels, 3-speed) – 50-FC-1616 Arm Length 14- ”, Leg Length 24- ”

Advanced Riders Only; must be able to make a pedal revolution on their own

□Option #1 – Standard Seating System: Saddle Seat and Simple Seatback with ” Hi-Rise Handle Bars

Seat Bottom Alternates	□ Padded Tractor Seat with bracket □ Pommel Saddle Seat □ Mediu		”	□ Large		x	”
Seat Bottom Alternates		(11.5x10	)		(		)

□Option #2 – Upgraded Seating System: Gray Bucket Seat

1616 Accessories:

□ ” Hi-Rise Handle Bars

□ 1400 Handlebars

□ Expanding Pedals

□1620 ProSeries FOOT TRYKE (with 20” wheels, 3-speed) – 50-FC-1620 Arm Length 18- ”, Leg Length 27- ”

Advanced Riders Only; must be able to make a pedal revolution on their own

□Option #1 – Standard Seating System: Saddle Seat and Simple Seatback with ” Hi-Rise Handle Bars

Seat Bottom Alternates:	□ Padded Tractor Seat with bracket □ Pommel Saddle Seat □ Mediu		”	□ Large		x	”
Seat Bottom Alternates:		(11.5x10	)		(		)

□Option #2 – Upgraded Seating System: Gray Bucket Seat

1620 Accessories:

□ ” Hi-Rise Handlebars

□ 1400 Handlebars

□ Expanding Pedals

□NEW! 2722 FOOT TRYKE (with ” wheels, single speed, hand & coaster break) – 50-FC-2722 Arm Length 22- ”, Leg Length 28- ” Advanced Riders Only; must be able to make a pedal revolution on their own

□ Option #1 – Standard Seating System: Large Saddle Seat (		x ”
Seat Bottom Alternates: □ Bench Seat □ Med Saddle (10.5x10) □ Padded Tractor Seat w/ Support Bracket: □ ” □ ”
	□ Pommel Saddle Seat □ Mediu	(11.5x10”) □ Large(	x	”)
Trunk Support Upgrades:	□ 2700 Back Support (with pad & 2 laterals)
Handlebar Upgrades: □ ProSeries Handlebars □ ”Hi-Rise Handlebars				□ Dual Hand Brake Lever □ Stem Riser
2722 Accessories:	□ Exercise Pedals □ Expanding Pedals □ Heel Pedal Leveler Pulley (only w/ Expanding Pedals)
	□ Calf & Leg Support (only w/ Expanding Pedals)		□ 2700 Angled Seat Post

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center	(800) 838-1845
Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org

This form, the Assessment Form and the Request/Waiver From must be received by your local chapter or the Resource Center before placement is considered.

Recipie t’s Na e:

□JT-2000 FOOT TRYKE (Recumbent 21 Speed) – 50-FC-2000 (advanced riders only)

JT-2000 Accessories:	□ Exercise Pedals	□ XL Exercise Pedals	□ Expanding Pedals □ Digital Speedometer
	□ Dual Hand Brake	□ Toe Clips	□ Rearview Mirror

□JT-2300-USS FOOT TRYKE (Recumbent 21 Speed with Under Seat Steering) – 50-FC-2300-USS (advanced riders only)

JT-2300-USS Accessories:	□ Exercise Pedals	□ XL Exercise Pedals	□ Expanding Pedals □ Digital Speedometer
	□ Dual Hand Brake	□ Toe Clips	□ Rearview Mirror

Therapist Assembly Notes or Comments (if any):

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center	(800) 838-1845
Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org

This form, the Assessment Form and the Request/Waiver From must be received by your local chapter or the Resource Center before placement is considered.

Recipie t’s Na e:

HAND-FOOT TRYKES

□ New! AM-10 HAND-FOOT TRYKE (with ”		ra k ar s) 50-HFC-0105 Arm length 12-16”, leg length 14-21”
□ Option #1 – Standard Seating System: Blue Bucket Seat
□ Option #2 – Upgraded Seating System: Snappy Seat System					□ XL Seat Back
Snappy Seat Accessories: □ Notched Seat Bottom Cushion* □ Notched Wide Bottom Cushion*					□ XL Seat Back
	□ Laterals		□ H-Harness: □ ” □	. ”
AM-10 Accessories:	□ Rear Steering Kit		□ Push Bar		□ Heavy-Duty Push Bar
	□ Pull/Steering Bar			*cannot be used with rear steering
				*cannot be used with rear steering


□ AM-12Small HAND-FOOT TRYKE (with ” ra k ar			s & ” wheels) 50-HFC-0110 Arm length 12- ”, leg le gth					-	”
Now comes standard with rear steering!
□ Option #1 – Standard Seating System: Bench Seat & 1600 Simple Seat Back
□ Option #2 – Upgraded Seating System: Snappy Seat System
Snappy Seat Accessories: □ Notched Seat Bottom Cushion* □ Notched Wide Bottom Cushion* □ XL Seat Back
	□ Laterals		□ H-Harness: □ ” □	. ”
□ Option #3 – Upgraded Seating System: Blue Bucket Seat
AM-12S Accessories:	□ Pull/Steering Bar		□ Toe Pedal Leveler Pulley		□ Exercise pedals
	□ Push Bar		□ Heavy-Duty Push Bar *cannot be used with rear steering

□ AM-12 HAND-FOOT TRYKE (with 4” ra k ar		s &	” wheels) 50-HFC-0210 Arm length 14-23”, leg length 21-29”
Now comes standard with rear steering!
□ Option #1 – Standard Seating System: Saddle Seat/1600 Simple Seat Back						”	□ Large		x ”
Seat Bottom Alternates:	□ Bench Seat	↴	□ Pommel Saddle Seat □ Mediu			”	□ Large		x ”
Seat Bottom Alternates:					(11.5x10	)		(	)
Trunk Support Upgrades:			□ ProSeries Head Rest □ ProSeries Full Padded Back
	□ ProSeries Seatback		□ ProSeries Head Rest □ ProSeries Full Padded Back
	(includes push grip, backpad & 2 laterals)
	□ ProSeries Lumbar Pad		□ ProSeries Back Spacer Kit
	□ H-Harness: □ ” □	. ”	□ AM Full Padded Back
□ Option #2 – Upgraded Seating System: Gray Bucket Seat
Bucket Seat Accessories:	□ H-Harness: □ ” □	. ”
	□ H-Harness: □ ” □	. ”
□ Option #3 – Upgraded Seating System: Snappy Seat System
Snappy Seat Accessories: □ Notched Seat Bottom Cushion □ Notched Wide Bottom Cushion □ XL Seat Back
	□ Laterals		□ H-Harness: □ ” □	. ”
AM-12 Accessories:	□ Pull/Steering Bar		□ Toe Pedal Leveler Pulley	□ Exercise pedals
	□ Knee Separator: □	” □	”

Please mail, email or fax completed form to your local chapter or AMBUCS Resource Center	(800) 838-1845
Mail: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org
This form, Request & Liability Waiver Form and Assessment Form must be received before placement is considered.

Recipie t’s Na e:

□ AM-16 HAND-FOOT TRYKE (with ” wheels) 50-HFC-0411 Arm length 18-27”, leg length 24-36”
Now comes standard with rear steering!
□ Option #1 – Standard Seating System: Saddle Seat/Gray Plastic Back
Seat Bottom Upgrades: □ Bench Seat			□ Padded Tractor Seat (used with ProSeries Seatback only)
	□ Pommel Saddle Seat □ Mediu		(11.5x10”) □ Large( x	”)
Trunk Support Upgrades: □ ProSeries Seatback		↴	□ ProSeries Head Rest □ ProSeries Full Padded Back
Trunk Support Upgrades: □ ProSeries Seatback			□ ProSeries Head Rest □ ProSeries Full Padded Back
	(includes push grip, backpad & 2 laterals)
	□ ProSeries Lumbar Pad		□ Proseries Back Spacer Kit
	□ H-Harness: □ ” □	. ”	□ AM Full Padded Back
□ Option #2 – Standard Seating System: Saddle Seat/1600 Simple Seat Back
Seat Bottom Upgrades: □ Bench Seat			□ Padded Tractor Seat (used with ProSeries Seatback only)
	□ Pommel Saddle Seat □ Mediu		(11.5x10”) □ Large( x	”)
Trunk Support Upgrades: □ ProSeries Seatback		↴	□ ProSeries Head Rest □ ProSeries Full Padded Back
Trunk Support Upgrades: □ ProSeries Seatback			□ ProSeries Head Rest □ ProSeries Full Padded Back
	(includes push grip, backpad & 2 laterals)
	□ ProSeries Lumbar Pad		□ ProSeries Back Spacer Kit
	□ H-Harness: □ ” □	. ”	□ AM Full Padded Back
□ Option #3 – Upgraded Seating System: Gray Bucket Seat
Bucket Seat Accessories: □ H-Harness: □ ” □		. ”
AM-16 Accessories:	□ Pull/Steering Bar	□ Toe Pedal Leveler Pulley		□ Exercise pedals	□ XL Exercise pedals
	□ Knee Separator: □	” □ ” □ K ee Separator ” Exte der Tube

□ New! AM-20 HAND-FOOT TRYKE (Recumbent Single Speed) – 50-HFC-0610 Arm length 18- ”, leg le gth - ”
AM-20 Accessories:	□ Exercise Pedals		□ XL Exercise Pedals	□ Expanding Pedals
	□ Wheelchair Seat Bar Ends		□ Swing Away Arms

Therapist Assembly Notes or Comments (if any):

Please mail, email or fax completed form to your local chapter or AMBUCS Resource Center	(800) 838-1845
Mail: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org
This form, Request & Liability Waiver Form and Assessment Form must be received before placement is considered.

Recipie t’s Na e:

HAND TRYKES

□ New! AM-10 HAND TRYKE – (4” Cra k Ar s & Per a e t Foot Platfor 50-HC-0105 Arm Length 12-16”

□Option #1 – Standard Seating System: Blue Bucket Seat

□Option #2 – Upgraded Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion □ Notched Wide Bottom Cushion □ XL Seat Back

□ Laterals

□ H-Harness: □

” □

. ”

AM-10 Accessories:

□ Push Bar

□ Heavy-Duty Push Bar

□ Pull/Steering Bar

□ Rear Steering Kit

□ AM-12Small HAND TRYKE – (

” Fro t Wheel & Per a e

t Foot Platfor

50-HC-0210S Arm Length 12-16”

Now comes standard with rear steering!

□ Option #1 – Standard Seating System: Bench Seat & 1600 Simple Seat Back

Trunk Support Upgrades:

□ AM Full Padded Back

□ H-Harness: □

” □

. ”

□ Back Spacer Kit

□ Option #2 – Upgraded Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion* □ Notched Wide Bottom Cushion* □ XL Seat Back

□ Laterals

□ H-Harness: □ ” □

. ”

□ Option #3 – Upgraded Seating System: Blue Bucket Seat

AM-12Small Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Knee Separator: □

” □

”

*cannot be used with rear steering

□ AM-12 HAND TRYKE – (

” Fro

t Wheel & Per

a e

t Foot Platfor 50-HC-0210 Arm Length 14-

”

Now comes standard with rear steering!

□ Option #1 – Standard Seating System: Saddle Seat/1600 Simple Seat Back

(11.5x10

)

(

)

Seat Bottom Alternates:

□ Bench Seat

□ Pommel Saddle Seat □ Mediu

□ Large

”

Trunk Support Upgrades:

□ ProSeries Head Rest

□ ProSeries Full Padded Back

□ ProSeries Seatback

backpad & 2 laterals)

(includes push grip,

↴

□ ProSeries Back Spacer Kit

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ”

□ AM Full Padded Back

□ Option #2 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories:

□ H-Harness: □ ” □

. ”

□ Option #3 – Upgraded Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion* □ Notched Wide Bottom Cushion* □ XL Seat Back

□ Laterals

□ H-Harness: □ ” □ . ”

AM-12 Accessories:

□ Pull/Steering Bar

□ Knee Separator: □

” □

”

*cannot be used with rear steering

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center	(800) 838-1845
Mail: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830	ambucs.org
This form, Request Form & Liability Waiver Form and Assessment Form must be received before Amtryke placement is considered.

Recipie t’s Na e:

□ AM-16 HAND TRYKE (	” wheels) 50-HFC-0411		Arm length 18-27”
Now comes standard with rear steering!
□ Option #1 – Standard Seating System: Saddle Seat/Gray Plastic Back
Seat Bottom Upgrades: □ Bench Seat						□ Padded Tractor Seat (used with ProSeries Seatback only)
	□ Pommel Saddle Seat □ Mediu				(11.5x10”) □ Large( x		”)
Trunk Support Upgrades: □ ProSeries Seatback		↴				□ ProSeries Head Rest □ ProSeries Full Padded Back

	(includes push grip, backpad & 2 laterals)					□ Proseries Back Spacer Kit
	□ ProSeries Lumbar Pad
	□ H-Harness: □ ” □	. ”				□ AM Full Padded Back
□ Option #2 – Standard Seating System: Saddle Seat/1600 Simple Seat Back
Seat Bottom Upgrades: □ Bench Seat						□ Padded Tractor Seat (used with ProSeries Seatback only)
	□ Pommel Saddle Seat □ Mediu				(11.5x10”) □ Large( x		”)
Trunk Support Upgrades: □ ProSeries Seatback		↴				□ ProSeries Head Rest □ ProSeries Full Padded Back

	(includes push grip, backpad & 2 laterals)					□ ProSeries Back Spacer Kit
	□ ProSeries Lumbar Pad
	□ H-Harness: □ ” □	. ”				□ AM Full Padded Back
□ Option #3 – Upgraded Seating System: Gray Bucket Seat
Bucket Seat Accessories: □ H-Harness: □ ” □		. ”
AM-16 Accessories:	□ Pull/Steering Bar			□ K ee Separator ” Exte der Tube
	□ Knee Separator: □	”	□ ”

□ COMMUNITY CRUISER HAND TRYKE – (			” Fro	t Wheel &		-Speed Drive Train) 50-HC-1424 Arm length 22- ”
CC Accessories:	□ Wheelchair Seat Bar Ends				□ Swing Away Arms		□ Remote location break and shifting kit

□ HP-1000 RECREATION HAND TRYKE – (7-Speed Drive Train) 50-HC-1000							Arm length 22- ”
HP-1000 Accessories:	□ Wheelchair Seat Bar Ends					□ Swing Away Arms

Therapist Assembly Notes or Comments (if any):

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center							(800) 838-1845
Mail: P.O. Box 5127, High Point, NC 27262	Email: ambucs@ambucs.org Fax: 336.852.6830						ambucs.org

This form, Request Form & Liability Waiver Form and Assessment Form must be received before Amtryke placement is considered.

Amtryke Sizing Chart

TRYKE TYPE	(How will the tryke be propelled?)	RIDER LEG LENGTH (Inches from center of hip to bottom of shoe.)	RIDER ARM LENGTH (Inches from middle of shoulder to center of	digit crease.)	MODEL	RIDER WEIGHT (Pounds)	RIDER MAX HEIGHT	(Inches)	TRYKE WEIGHT	(Pounds)	WHEEL SIZE	(Inches)	TTRYKE HEIGHT	(inches)	TRYKE LEGNTH	(inches)	TRYKE WIDTH	(Inches)
	& Foot	14-21	12-16		AM-10	175		40		45		11		24		38		21
		18-22	12-16		AM-12S	150		40		45		12		27		38		24
		21-29	14-23		AM-12	150		47		45		12		36		60		32
	Hand	24-36	18-27		AM-16	175		66		55		16		36		68		33
	Hand	32-46	18-30		AM-20	250		74		80		20		45		72		32
		14-21	7-20		1410	175		40		45		11		24		38		21
		17-22	9-13		Snappy	150		42		45		12		30		38		24
		21-26	14-22		1412	125		42		72		12		13		43		27
	Foot	24-32	14-22		1416/1616	175		60		74		16		49		58		30
		27-35	18-28		1420/1620	250		68		74		20		50		64		30

		28-43	20-32		1420XL	275		76		89		20		43		72		29
		28-36	22-30		2722	275		72		76		24		42		60		30
		30-41	20-28		JT-2000/	250		74		80		20		48		72		32
		30-41	20-28		JT2300USS	250		74		80		20		48		72		32
					JT2300USS
	Hand	22-41	22-26		1424	250		72		74		20		45		75		32
											Front 16
		N/A	22-26		HP-1000	250		74		80	Rear 20			45		72		32
											Rear 20
		All trykes in the Hand & Foot section can be converted to Hand trykes – except the AM-20.

A Center of Shoulder

B Center of Elbow

C Center of Digit Crease

D Center of Hip

E Center of Knee

F Bottom of Foot

RIDER'S MEASUREMENTS

Arm Measurements (inches) Total Length

Left	A to B	+	B to C = __________
Right	A to B	+	B to C = __________
Trunk			A to D = __________

Leg Measurements (inches) Total Length

Left	D to E + E to F	=	__________
Right	D to E + E to F	=	__________

HELMET SIZING

Youth Sizes	Head Circumference Inches
XXS	18.5 to 19.5
XS	20 to 21
S/M	21.5 to 22.5
L/XL	22.75 to 24.5
Adult Sizes	Head Circumference Inches
S/M	22 to 23 5/8
L/XL	23 5/8 to 25 3/4

Updated 10/10/15

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