WAIVERS/INTAKE FORM — Adaptive Mobility Providers

Skip to Content

WAIVERS/INTAKE FORM

SPONSORS & AFFILIATES

WAIVERS/INTAKE FORM

SPONSORS & AFFILIATES

WAIVERS/INTAKE FORM

SPONSORS & AFFILIATES

SIGN WAIVERS HERE by using your smartphone to scan below or click on link:

AMP RELEASE OF LIABILITY AGREEMENT

MOVE UNITED RELEASE OF LIABILITY AGREEMENT

MOVE UNITED MEDIA RELEASE

Electronic waiver forms provided by

INTAKE FORM

Name *

First Name

Last Name

Gender *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Attendee Type

Check All That Apply

Civilian W/Disability

Veteran W/Disability

VA Partner Staff

Community Partner

Volunteer

Family Friend/Caregiver

Disability Info

Check All That Apply

Amputee: Above-Knee

Amputee: Below-Knee

Amputee: Arm

Cerebral Palsy

SpPina Bifida

Hearing Impairment

Multiple Sclerosis

Muscular Dystrophy

PTSD

Spinal Cord Injury

Stroke

TBI

Visual Impairment

Other

Medical Info *

Medications

History of Seizures?

Yes

No

Other

Is There Anything Else AMP Should Know?

Military Only

Branch Of Service

Rank

Injury Date

Served Post 9/11?

Yes

No

Service-Related Injury?

Yes

No

Are You Eligible To Receive VA Services and Not Barred? *

Yes, I'm Eligible

No, I Am Not Eligible

Thank you!

Adaptive Mobility Providers, Inc.
info@AdaptiveMobilityProviders.org

AMP is a 501(c)(3) Non Profit Organization EIN 33-2049907