REGISTRATION FORM (Please Print Legibly)

 

Name _____________________________________________________

Facility Name _______________________________________________

Work Mailing Address ________________________________________

City _____________________ State __________ Zip _________

(W) Phone ___________________     (H) Phone ___________________

Fax ________________                    E-mail _____________________

____ Building Blocks - Cost $850.00 Date ____________
____ Take the Wheel - Cost $850.00 Date ____________
____ Green Light For A Van Prog - Cost $875.00 Date ____________
____ Bioptic Driver Course - Cost $600.00 Date ____________
TOTAL: $ ____________________________  

YOU MUST SEND VERIFICATION OF ALLIED HEALTH BACKGROUND WITH REGISTRATION

 

HOW TO REGISTER

Mail Registration form, allied health license and check payable to:

Adaptive Mobility Services, Inc.

VIN # 59-2992263
1000 Delaney Avenue
Orlando, FL 32806-1228

(407) 426-8020

No Credit Cards Accepted
Sorry, we cannot reserve spaces
without receiving payment.