Upright HandcycleAGE: 7–14 Years INSEAM: 19"–26"

RIDER INFORMATION Male Female

Rider’s Name: ____________________________________________________

Date of Birth: MONTH ____________ /DAY ____________ /YEAR ___________

Diagnosis: ________________________________________________________

Weight: _______lbs. _______kgs. Height: _______inches _______cm

A. Seat Depth: ________________ inches ___________ cm

B. Inseam: __________________ inches

_____________________ cm

C. Back Height: _______________ inches

__________________ cm

D. Seat Width: _______________ inches ___________ cm

THERAPIST’S Name: ______________________________________________

Phone: ___________________________________________________________

Fax: ____________________________________________________________

Email: ___________________________________________________________

A

C D

B

PAGE SUB-TOTAL

CHAIN GUARD (Foot Drive Only)E. Total Length: 50" WG: 50” F. Rear steering allows bike to be

controlled from the rear, this adds 12" to the length of the model.

G. Width: 29" WG: 33” H. Steering head tube

unlocks/locks steering

E G*Maximum Weight on Removable Rear Platform is 25 lbs.

TOTAL

REAR STEERING

NEW

FH

PEDAL POWER (Applicable only to single speed hand or foot drive)

Easy (std)

Average (n/c)

Challenging (n/c)

H F

H FH F

COLOR CHOICE

Please note extra delivery time for N/c & custom colors.

Foot Platform (for hand power only)

Molded ABS Footplate System* XS S M L XL (std)

BOTTOM BRACKET POSITION

M. Position of bottom bracket in relation to the seat post. M

W E C A N C U S T O M B U I L D B A S E D O N Y O U R S P E C I F I C N E E D S !

PROPULSION

3-Speed Freewheel w/ Coaster Brake (std)Twist Grip Shift

TEC Drive - 3-Speed Direct Drive (eAsY, AVeRAge, chAllenging)

(eAsY, AVeRAge, OFF)

(std) PLEASE NOTE: Standard shift mechanism for TEC and REC drives.

NEW

H F

H FF

H F

H F

U-Bar R.S. R. Pedal

U-Bar R.S. R. Pedal

H F

NEW

CRANK ARM LENGTHS - RANGE OF MOTION

I J K L

H F

H FH F

PARKING BRAKE

FRAME CHOICE: Hand Only (n/c) Hand & Foot ($501.50)

EHD U16N (Narrow) $3,382.99EHD U16 WG (Wide Glide) $3,464.50Custom Frame (call for price)

Removable Rear Platform* $296.12

Rear Steering $570.59

Adjustable Jogging Extension Handle $170.75

Candy Blue Hot Rod Purple (std)

Blue Red Yellow Pink

Other Custom Color

Please Specify: ____________________

Sticker Type Male Female

Direct Drive (n/c)

Free Wheel

Manual Free Wheel / Direct Drive Reciprocator System

REC - 2-Speed Direct Drive w/ Neutral

Thumb Shift Lever

(std)Thumb Shift Lever

Shorter range is suitable for limited knee flexion.

I. 3" (79mm) x 26T (n/c)

J. 4" (102mm) x 32T (std)

k. 5” (127mm) x 32T (n/c)

L. Crank Shortener (reduces length by 1/2”)

Standard (3") (n/c)

Custom ________inches ________cm $170.75

Heavy Duty Steel Chain Guard (std)

ABS Enclosed Chain Guard (N/A with TEC and REC Drive)

Parking Brake (std)Second Parking Brake

Upright Handcycle Evaluation Form (Jan 19/16) Effective January 19, 2016 Page 1

PAGE SUB-TOTALCreating a CYCLE of mobilityTM

SEAT BASE

1415

8 9 10 11 12 13 16

BRAKE LEVER POSITION

P Q

ON

WHEELS

BACK REST (***Seat is cut away for arm movement)

Chest Strap (High Back only) (std)

17. Child Low Back - (13" width, 7.5" height) (n/c)18. Child High Back*** - (13" width, 18" height) (std)

(Includes Custom Back) (2 Required for Set)

A. chesT WidTh ______ inches ______ cm b. seAT TO ARmpiT ______ inches ______ cm

17

AB

18 19 20 21 22

TIRES

PEDALSMeasure Rider’s Shoe: i) _____ inches _____ cm ii) ______ inches ______ cm OR TRACE OUTLINE OF RIDER’S SHOE ON A PIECE OF PAPER & SUBMIT w/ORDER.

5 76

3 42

ii

i

Shoe Heel Widest Point

Shoe length

1

HAND PEDALS

R S T U V

HEAD REST

PLEASE NOTE: Required for addition of Adjustable Rain and Sun Shade Canopy

24. Adjustable Velcro Occiput Support Cushion PLEASE NOTE: Includes Adjustable/Removable Headrest option.

25. i2i Head & Neck Support System with Support Bracket PLEASE NOTE: Please specify size as per brochure.26. Headpod Support System with Support Bracket PLEASE NOTE: Includes Adjustable/Removable Headrest option.

Custom - Custom Mount of Head Support Bracket (Template required) (call for price)

heighT: ________ inches ________ cm WidTh: ________ inches ________ cm

Adjustable Rain & Sun Shade Canopy PLEASE NOTE: Requires the Adjustable/Removable Headrest

26252423

N. 16" Aluminum (std)O. Spoke Covers (set of three)

P. 16" Smooth Solid Tires (Aluminum Wheel only) (std) Q. 16" Knobby 16” Smooth

Coaster Brake (std)Front Brake (Please specify 1st lever position) (n/c)

Second Brake Lever* (splitter)

Optional Rear Band Brake (EHD U16WG only)*

LEVER POSITIONING 1st LEVER (std) 2nd LEVER*

Left Pedal

Right Pedal

Rear Assistance (T-bar)

Rear Steering Handle

Effective January 19, 2016 Page 2

6. Pulley System (FRONT: corrects plantar flexion) Pulley System (REAR: self-leveling pedals) 7. Abductor Leg Brace *requires #5 Molded ABS Footplate S M L

1. Mountain Style Pedal (std) 2. with Cage ($42.65)3. Neoprene Adjustable Footplate* S M L XL 4. Molded ABS Footplate System* XS S M L XL5. Molded ABS Footplates with Ratcheting Straps Size Options: XS S M L XL

Please specify Left or Right 0.25” Footplate Spacers Qty: ______/Pedal ($13.66/uniT)

R. Bar End Grip Pedals (std)S. T-Handle Pedal (required for brake lever on pedal) T. Quad Cuff Grip U. Foam Covered Straight Grip V. Foam Covered Ergo Grip

8. Child (12.5" width, 12.5" depth) (std)9. Child Narrow

10. Adult Seat (16.75" width, 14" depth) (WG only)

11. Adult Narrow (WG only)

12. Add 2" Raised Pommel to seat selection above

13. Custom (measurements) (call for price)

A. ________ inches ________ cm B. ________ inches ________ cm

14. Hip Belt 1.5" wide (n/c)

15. Hip Belt, 2" wide (std)16. Neoprene Hip Stabilizer Belt

19. Adult Low Back - (17" width, 10" height) (WG only) 20. Adult High Back*** - (17" width, 18" height) Recline bAck 21. TilT seAT

22. Lateral Support Bracket complete w/Track S L ($352.71/EA)

23. Adjustable/Removable Headrest

CHEST HARNESS

Creating a CYCLE of mobilityTM

STATIONARY TRAINER

Total - Page 3

Total - Page 2

Total - Page 1

SUB-TOTAL

TOTAL

ABDUCTOR/ADDUCTION

27 28

GLOVES

Hand Tracing RequiredB

A

A. Measure width of palm _____ inches _____ cm

B. Measure width of wrist _____ inches _____ cm

C. Measure bend of wrist to top of middle finger _____ inches _____ cm

C

PRIVACY POLICYFreedom Concepts Inc. collects, uses and discloses personal information of the Customer and/or Rider to properly assemble and manufacture the mobility deviceand may contact the Rider’s therapist for additional personal information to assistwith this process. The collection, use and disclosure of the personal informationof the Customer and/or the Rider is governed by any consent which may, from timeto time, be provided, and by the Freedom Concepts Inc. Privacy Policy which isavailable on our website www.freedomconcepts.com or by contacting our office.By signing below, you hereby warrant that you have the authority to bind the Riderand hereby authorize the collection, use, and disclosure of personal information asherein provided and in accordance with the Freedom Concepts Inc. Privacy Policy.

TERMS & CONDITIONSPrices are subject to change without notice. Prepaid or net 30 days O.A.C.All taxes extra. Freight extra. Manufacturer reserves the right to change prices,colors, features, dates, locations and products without notice. Residentialdelivery charge may apply. Duty and brokerage included where applicable.

SIGNATURE OF RIDER/PARENT

I hereby give permission to Freedom Concepts Inc. to use photographs of me or my child for the sole purpose of the company’s promotional use, and will not be distributed to third parties. YES NOI would like to receive regular updates. SNAIL MAIL EMAIL NO

CUSTOMER SIGNATURE

CUSTOMER INFORMATIONDealer/Vendor: ______________________________________________________

Contact Person: _____________________________________________________

Address: ___________________________________________________________

City: ________________________ Prov./State: ___________________________

Postal/Zip Code: _____________ Ordered by: ___________________________

Phone: ____________________________ Fax: ___________________________

Email: _____________________________________________________________

ORDER INFORMATIONPurchase Order: _____________________________________________________

Order Date: __________________________________ Quote Date: ____________

FCI Representative: __________________________________________________

Payment Terms: _____________________________________________________

CREDIT CARD (check One) Visa MasterCard Exp. Date: ___________

Card Number: _______________________________________ __________

Name On Card: _________________________________________________

Signature: ______________________________________________________

SHIPPING INSTRUCTIONS

Name: _____________________________________________________________

Address: ___________________________________________________________

City: _______________________________________________________________

Province/State: ______________________________________________________

Postal/Zip Code: ________________ Phone: ______________________________

Federal ID/SS#: ______________________________________________________

ACCESSORIES

Self Centering Spring Locking Hand Brake (std) Safety Flag Wheel Reflectors (std)

Effective January 19, 2016 Page 3

Neoprene Chest Harness - Medium

Neoprene Chest Harness - Large

Neoprene Chest Harness - Extra Large

X Small Small Medium Large

Custom (call for price)

Indoor Stationary Trainer

27. Abductor (Removable Leg Divider)

28. Padded Leg Adduction Strap

Residential Delivery (N/C)

Tax 1

Tax 2

Other

Boxed (Some assembly required) ($100.00)

Freight (crated) ($250.00)

Animal Squeaky Horn (n/c)Multitool (sold separately $16.00) (std)Bell (std)Tool Pouch Bike Covers Cane/Crutch Holder Oxygen Tank Holder (Specify Tank Size _____________)iPad/Tablet Holder Communication Tray Simulated Sheepskin Seat Cover Child ($118.60) Adult ($132.78)