Kiddie Pool Sign up form

[click here to print form]

Caregiver's First Name:
Last Name:
Caregiver's Email:
Child's Name:
(first and last initial)
Child's Gender:
Child's School Grade
(if attending):
Child's Age:
Please indicate the month and date of your child’s birthday. This is so that we can send you a special email about your child’s Kiddie Pool before their birthday for you to send to friends and family if you choose to do so.
Child's Date of Birth (Month):
Child's Date of Birth (Date):

Step I - Shipping Information

(Certain items cannot be shipped outside of the contiguous 48 states. We will notify you if this is the case with any item choose. If the item can be shipped outside of the contiguous 48 states, shipping charges will apply)
Shipping Address:
Shipping City:
Shipping State:
Shipping Country:
Shipping Zip Code:
Shipping Phone Number:
What is your child's disability?
When was your child diagnosed with this disability?
Upload a picture of your child here:
[Please note: We can only accept images in jpg or gif format. If you upload other type of files, we will not receive them. Size limit is 2mb]
Products Desired with Item#:
Total Price of all Product(s) Desired (Dollar Amount Goal):

Step II - Questions for Fun Facts section:

Do you attend school? If yes, what is your favorite subject?
Do you participate in adaptive sports or other community events? What is your favorite?
What challenges/obstacles do you encounter?
What do you want people to know about you?
What are your favorite hobbies?
Describe a day in the life of you.
What is your favorite color?

Step III - Additional Questions:

Would you like to write your child’s “About Me” section? If yes, please include it below. If not, Adaptivemall.com will write it for you based on the answers given above.
Would you like to use our custom email, or would you like to create your own email to send to your friends and family?

*Adaptivemall.com requires your permission to use your child’s first name & last initial and age on our website. No geographical or address information will be used.

*Your dollar amount goal is based on the product and accessories current price. Actual order total is subject to change based on price changes set by each manufacturer. If a price increase has occurred, you have two options.

1. Increase your goal amount
2. Put acquired funds on credit with Adaptivemall.com for later use

*Donations are like gift certificates. They can only be redeemed for product or credit on account with Adaptivemall.com. They cannot be refunded.

*After your goal is met and before your order is placed, Adaptivemall.com will verify sizing with our staff therapists.

By emailing this form to Adaptivemall.com, you agree to the terms and conditions of the Kiddie Pool Program.

Comments?
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