Kids on the Go/Adapt My World Application Pre-Screening
The Kids on the Go /Adapt My World program is not accepting formal applications at this time, however sometimes we can help off-cycle or make a referral. Please fill out the following and we will be in touch with more information or when applications open. Thank you for your patience! 
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Parent Contact Information (Name, Address, Phone, Email)  *
Name, age and diagnosis of child(ren) who the  equipment is for.  *
Please enter the product number
What item are you requesting (please be as specific as possible as many items have multiple styles and models)  *
We will require a prescription or short note from your child's OT/PT or doctor stating why this item will be beneficial to you or your child. Thank you for providing this information, we will be in touch soon.   
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