2018 evaluation form explorer series balance bike · animal squeaky horn (n/c) multitool (sold...
TRANSCRIPT
EX BB6
EXPLOREREX BB6 EX BB8
Rider Age (Years) 6–12 6–12Rider Inseam 16”–26” 16”–26”Max. Load (lbs) 125 225Bike Weight (lbs) 48 63Wheel Size 6” wide 8.5” wide Frame Height 23” 29”(without Seat)
Total Length 46”* 61”(*with Heavy Duty Assistance Handle add 6”)
Bike Width 12” 17”
2018 Evaluation Form
Explorer SeriesBalance BikeEX BB6” and EX BB8”AGE: 6–12 YearsINSEAM: 16"–26"
Made for those active riders, the Explorer Series gets back to Freedom Concepts’ roots with a focus on the rider who just needs a little something extra to help them move along.
The Balance Bike is designed as a true therapy tool for use in a clinical setting. The device can be used to transition the rider from a bicycle with training wheels to one without.
1 .800.661.9915 www.freedomconcepts.com
S t a n d a r d F e a t u r e sHigh Rise Handlebars with InfiniteSteeringAdjustment
Heavy Duty Steel Chain GuardMountain Style Pedals
O p t i o n s Footplates
Heavy Duty Assistance Handle (A)Seat Back Support (B)
(A)
(B)
BB6/BB8AGE: 6-12 YEARS INSEAM: 16"–26"
EX BB FRAME CHOICE
E. Total Length: BB6 - 46” / BB8 - 61” F. Width: BB6 - 12” / BB8 - 17”
PEDAL POWER
Easy
Average (std)Challenging
E F
BOTTOM BRACKET POSITION Standard (6.5") OR Custom
_______________inches _______________cm
L. Position of bottom bracket in relation to the seat post.
Bottom Bracket (see inseam) Up Down (std)
RIDER INFORMATION
Rider’s Name: ____________________________________________________
Date of Birth: MONTH ____________ /DAY ____________ /YEAR ___________
Therapist’s 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
PROPULSION
Direct Drive (std)
Free Wheel
EX BB6
EX BB 6 Special Edition (Special Edition includes: HD Assistance Handle & Seat Back Support)
EX BB 8
Heavy Duty Assistance Handle
Custom Frame call for price
TOTAL
BOTTOM BRACKET WIDTH
K. Standard Crank 6" Wide (std)
Custom Crank
K
PAGE SUB-TOTAL
COMMENTS
Balance Bike Evaluation Form (Jan 31/18) 1.800.661.9915 fax 204.654.1149 Effective January 31, 2018 Page 1
COLOR CHOICE
Candy Blue Hot Rod Purple (std)
Blue Red Yellow Pink
Other Custom Color
Please Specify: ____________________
Sticker Type Male Female
Please note extra delivery time for non-standard & custom colors.
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 !
L
Shorter range is suitable for limited knee flexion.
G. 3" (79mm) x 26T Alloy Crank (n/c)
H. 4" (102mm) x 32T Alloy Crank (std)
i. 5” (127mm) x 32T Alloy Crank (n/c)
J. Crank Shortener (reduces length by 1/2”)
CRANK ARM LENGTHS - RANGE OF MOTION
G H I J
FORK
Tubular Steel Fork (std)
TIRES
6” Wide - All Terrain Tires (BB6 only) (std) 8.5” Wide - All Terrain Tires (BB8 only) (std)
HANDLE BAR BASE HEIGHT (*) 12” Height (n/c)
6.5” Height 9.5” Height
CHAIN GUARD
Heavy Duty Steel Chain Guard (std)
BRAKE LEVER POSITION
Back Brake (std)Front Brake
LEVER POSITIONING Rear Brake Front Brake
Left Handlebar
Right Handlebar
Rear Assistance Handle
PAGE SUB-TOTAL
Creating a CYCLE of mobilityTM 1.800.661.9915 www.freedomconcepts.com Effective January 31, 2018 Page 2
SEAT BASE
8. Back Support9. Bicycle Saddle-Style Seat (std)Chest Strap (Back Support Only) (std)
9
COMMENTS
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 !
8
HANDLE BARS Steering Locked Steering Unlocked
M. Wide (std)
N. Hoop
O. Small Hoop
P. High Rise
i. Bar End Extensions
ii. Nameplate Special Dedication Company Logo
16"
i
iiM
O
N
P
18"
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.
1. Mountain Style Pedal (std) 2. with Cage 3. Neoprene Adjustable Footplate* S M L XL 4. Molded ABS Footplate System* XS S M L XL (5. Molded ABS Footplates with Ratcheting Straps
Size Options: XS S M L XL 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
Please specify Left or Right 0.25” Footplate Spacers Qty: ______/Pedal
5 76
3 42
ii
i
Shoe Heel Widest Point
Shoe length
1
Creating a CYCLE of mobilityTM 1.800.661.9915 www.freedomconcepts.com January 31, 2018 Page 3
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 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 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#: ______________________________________________________Total - Page 3
Total - Page 2
Total - Page 1
SUB-TOTAL
Boxed (Some assembly required)
Freight (crated)
Residential Delivery
Tax 1
Tax 2
Other
TOTAL
ABDUCTOR/ADDUCTION10. Abductor (Removable Leg Divider)
11. Padded Leg Adduction Strap M L
10 11
GLOVES
Hand Tracing RequiredB
A
X Small Small Medium Large
Custom
A. Measure width of palm_____ inches _____ cm
B. Measure width of wrist_____ inches _____ cm
C. Measure bend of wristto top of middle finger
C
ACCESSORIES
Self Centering Spring Locking Hand Brake (std) Safety Flag Wheel Reflectors (std)
Animal Squeaky Horn (n/c)Multitool (sold seperately) (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 Adult