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Account

Kiddie Pool Sign-Up Form

Caregiver's First Name:
Caregiver's Last Name:
Caregiver's Email:
Child's Name:
(first name and last initial only)
Child's Gender:
Child's School Grade
(if attending):
Child's Age:
Child's Date of Birth (Month/day):

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 (Please include name of product and Item#):
Total Price of all Product(s) Desired (Dollar Amount Goal):

Step II - Child’s Fun Facts:

Does he/she attend school?
If yes, what is his/her favorite subject?
Does he/she participate in adaptive sports or other community events? What is his/her favorite?
What challenges/obstacles does he/she encounter?
What do you want people to know about him/her?
What are his/her favorite hobbies?
What is his/her 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.

*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.

Would you like to receive our Adaptivemall Weekly Newsletter with information on products, sizing tips and more? Please list your email below:

Comments?

IMPORTANT: Please add @adaptivemall.com and @bergeroncompanies.com to your safe list in your email program. Please check your spam folder within the next week to be sure you are receiving emails from us regarding the Kiddie Pool!

Please enter the code in the box (this lets us know you're a person):
Please note: If you've uploaded an image, you may need to wait a moment after clicking the button above for the photo to upload to us!