G

ASR 2011AGE: 10+ YEARS INSEAM: 19"+

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

ASR 2011 Evaluation Form (Jan 19/16)

PAGE SUB-TOTAL

E. Total Length: 77" F. Rear steering allows bike to be

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

G. Width: 35"/31” (Narrow)H. Steering head tube

unlocks/locks steering• Transfer Height: 14”

F

H

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

FRAME CHOICE

(Not available with Rear Steering™)

CHAIN GUARD

Heavy Duty Steel Chain Guard (std)

TOTAL

REAR STEERINGRear Steering

PROPULSION

NEW

BOTTOM BRACKET WIDTHStandard Crank 6" Wide (std)

Note: All devices can tip, but by narrowing the frame, the risk becomes greater. A waiver is always included with this bike.

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 !

COLOR CHOICE

Direct Drive (std)

TEC Drive - 3-Speed Direct Drive

Shift Lever Location RIGHT RS

NEW

NEW

PEDAL POWER (For Single Speed only) Easy (n/c) Average (std) Challenging (n/c)

Shorter range is suitable for limited knee flexion.

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

J. 4” (102mm) x 32T Alloy Crank (n/c)

K. 5” (127mm) x 32T Alloy Crank (STD)

CRANK ARM LENGTHS - RANGE OF MOTION

I J K L

FORK

Chrome Fork (std)Suspension Fork (Required when Disc Brakes are ordered)

ASR 2011 (Includes std Bold Items) $3,748.77ASR 2011 Narrow $3988.52ASR 2011 HD (Heavy Duty) $4,171.42Custom Frame (call for price)

Candy Blue Hot Rod Purple (std)

Blue Red Yellow Pink

Other Custom Color

Please Specify: _____________________________

Sticker Type Male FemalePlease note extra delivery time for non-standard & custom colors.

Removable Rear Platform* (Required for Electric Assist) $368.15

$570.59 Adjustable Jogging Extension Handle ADD $170.75

Free Wheel

Manual Free Wheel / Direct Drive Reciprocator System

(eAsY, AVeRAge, chAllenging) R Rs

REC - 2-Speed Direct Drive w/ Neutral(eAsY, AVeRAge, OFF) R Rs

Thumb Shift Lever (STD)

Nexus 8-Speed Drive

Electric Assist

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

Effective January 19, 2016 Page 1

Creating a CYCLE of mobilityTM

TIRESO. 20" Smooth (std)

O

NM

P

WHEELS

PARKING BRAKE (transfer purposes)

LEVER POSITIONING FRONT BRAKE REAR BRAKELeft Handlebar Right Handlebar Rear Assistance (T-bar) (n/A) (n/A)Rear Steering Handle

BRAKE OPTIONSFRONT BRAKE REAR BRAKE

Vee Brakes (std) Disc Brakes (std)

BRAKE LEVER POSITION

14

158 9 10 11 12 13

SEAT BASE

BACK REST

Chest Strap (High Back only) (std)

18. Adult Xtended-High Back (17” width, 22” height)

(Includes Custom Back) (2 Required for Set)

A. chest WiDth ______ inches ______ cm b. seAt tO ARmpit ______ inches ______ cm

Custom (call for price)

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

NEW

16

AB17

18

19

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.

Please specify Left or Right

5 76

3 42

ii

i

Shoe Heel Widest Point

Shoe length

1

HEAD REST

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

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

22. i2i Head & Neck Support System with Support Bracket PLEASE NOTE: Please specify size as per brochure.23. 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

23222120

HANDLE BARS Steering Locked Steering Unlocked

R. High Rise (n/c) S. Wide (n/c)

R ST

i

ii

PAGE SUB-TOTAL

NEW

M. 20" Aluminum (std)20” HD Wheels (included on hD n/c) ($301.26)Removable Wheels N. Spoke Covers (set of three)

P. 20" Knobby

Parking Brake (Right Rear Wheel) (std)Second Parking Brake (Left Rear Wheel)

Disc Brakes ($165.33) *Must have Suspension Fork Coaster($102.01) - Nexus 8-Speed Only -

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 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

0.25” Footplate Spacers Qty: ______/Pedal ($13.66/unit)

T. Hoop (std)

i. Bar End Extensions

ii. Nameplate Special Dedication ($42.65) Company Logo($74.36)

8. Child (12.5" width, 12.5" depth) (n/c)9. Child Narrow 10. Adult Seat (16.75" width, 14" depth) (std)11. Adult Narrow 12. Add 2" Raised Pommel to seat selection above 13. Custom (measurements) (call for price)

A. ________ inches ________ cm B. ________ inches ________ cm14. Hip Belt, 2" wide (Large Size) (std)15. Neoprene Hip Stabilizer Belt

16. Child High Back - (13" width, 18" height) 17. Adult High Back - (17” width, 18” height) (std)

Effective January 19, 2016 Page 2

20. Adjustable/Removable Headrest

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

Creating a CYCLE of mobilityTM

STATIONARY TRAINER

Total - Page 3

Total - Page 2

Total - Page 1

SUB-TOTAL

TOTAL

ABDUCTOR/ADDUCTION

24 25

GLOVES

Hand Tracing RequiredB

A

_____ 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#: ______________________________________________________

CHEST HARNESS

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)

A. Measure width of palm

Animal Squeaky Horn (n/c)Multitool (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)

Freight (crated) ($200.00)

Residential Delivery

Tax 1

Tax 2

Other

Indoor Stationary Trainer

24. Abductor (Removable Leg Divider)

25. Padded Leg Adduction Strap