Purchase Belt Cane Form

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Purchase a Complete Pediatric Belt Cane Set

CONTACT INFORMATION

PREFERRED METHOD OF CONTACT * Required

Text Message

Phone Call

Postage Mail

SHIPPING ADDRESS

SHIPPING PREFERENCE * Required

Free Shipping (Shipping times may vary)

Please send me an estimate price for shipping for USPS / UPS / FEDEX

CHILD'S INFORMATION

CHILD'S MEASUREMENTS

VIEW STANDARD SIZE CHART

Hip width: Inches from hip to hip (ruler)

Waist circumference: Inches around waist (measuring tape, Hip 6)

Waist circumference: Inches around waist (measuring tape, Hip 7)

Waist circumference: Inches around waist (measuring tape, Hip 8)

Waist circumference: Inches around waist (measuring tape, Hip 9)

Height to shoulder: Inches floor to shoulder (Hip 6)

Height to shoulder: Inches floor to shoulder (Hip 7)

Height to shoulder: Inches floor to shoulder (Hip 8)

Height to shoulder: Inches floor to shoulder (Hip 9)

Does child receive any of the following services: * Required

Orientation and Mobility

Physical Therapy

Occupational Therapy

Other

If yes, where have the mobility devices been used?

Home

School

During Therapy Sessions

Other

Select an item ($) *

Complete Belt Cane Set (2 Frames) - $288.67

Standard Belt Cane Set - $206.28

**The price per unit includes online payment fees.

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SAFE TODDLES INC.

1491 Route 52, Suite 44,

Fishkill, NY 12524

info@safetoddles.org

845-244-6600

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"Every donation gifts toddlers who are blind with a solution for walking independently with safety."

Contact Safe Toddles at info@safetoddles.org or 845-244-6600

Manufactured by Safe Toddles Inc.

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