Online Bugzi Application

Child's Details
Preferred assessment centre*
Child’s Full Name*
Date of Birth*
Gender*
Home Address*
Street Address Town/City County Postcode

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Parent/Guardian/Carer Details
Parent/Guardian Name*
Email*
Contact / Mobile Number*
Your relationship to the child*
Please indicate if there is anyone else that you would like us to share this information with. e.g. other parent*
Their Name*
Their contact number*
Their email address*
Child’s Professional*
Job title*
Phone*
Email*

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Seat Measurements
SEATING DIMENSION (cm/kg)
Seat Depth in CM*
See image arrow D

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Seat Measurements
Leg Rest Length (A) in CM (MAX 33cm)*
See image arrow A
PLEASE NOTE THIS FIELD SHOULD NOT BE GREATER THAN 33CM (Please contact us if your child's measurement are greater)

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Seat Measurements
Seat Width (E) in CM*
See image arrow E

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Seat Measurements
Shoulder height (B) in CM*
See image arrow B

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Seat Measurements
Thoracic pad height (C)*
See image arrow C
Current Weight (MAX 25KG)*
Finally please enter weight - 25KG which is approx. 3.9 Stone

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About your child
What is your child’s diagnosis?*
Please tell us if your child’s condition affects their visual, sensory or cognitive abilities, or if they suffer fits or tics. Does your child use a ventilator or require oxygen that which would need to be mounted on Bugzi?
How does your child move their arms, legs and head, as well as their whole body?*
How does your child express themselves - do they talk, use signing, use pictures, use special sounds?*
How does your child use electronic controls in other activities? e.g. switches, joysticks, tablets, phone*
What are the best positions for the controls they use?*

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Using Bugzi
How many days a week do you anticipate Bugzi will be used?*
And for how many minutes on those days?*
What do you hope your child will learn by using Bugzi?*
What impact do you think Bugzi may have on your child’s participation in their family, school and social life?*
Where is Bugzi going to be used? e.g. Home, School, etc
How will you safeguard against hazards? e.g. Downward steps, tables, shelves, floor lamps, etc.*
Terms of application
Please sign below to confirm that you have understood the followingYou must attend one of our partner centres for initial assessment.
Terms of Service*
- I agree to the Terms of bugzi loan scheme
On occasion, supporters of the Bugzi Loan Scheme request information or an image of a child in Bugzi. Please check this box if you would be happy to giving your consent at the assessment.
- I agree
Please enter parents/guardian name below and sign.
by entering your name this will be deemed as your signature
Name
First Last
Date:*
Where did you hear about Bugzi?*
Ethic Origin*
We are obliged to ask this information from the organisations that fund our service. You do not have to answer these questions, and if you choose not to, this will not make any difference to the service you receive. This section of the application form will be detached and the information collected will only be used for monitoring purposes in an anonymous format.
Please specify ethic origin*
Subscribe to receive emails from MERU and QEF with offers and news about our work to support disabled people
Agree to privacy/GDPR
- I agree that the data submitted will be used in connection to the loan of Bugzi and have read and agree to the privacy policy
Email
This field is for validation purposes and should be left unchanged.

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Designing & building assistive equipment
for people with disabilities

Online Bugzi Application

Step 1 of 9 - Child's Details

Child's Details

Parent/Guardian/Carer Details

Seat Measurements

SEATING DIMENSION (cm/kg)

Seat Measurements

Seat Measurements

Seat Measurements

Seat Measurements

About your child

Using Bugzi

Terms of application

Please sign below to confirm that you have understood the followingYou must attend one of our partner centres for initial assessment.

Please enter parents/guardian name below and sign.

by entering your name this will be deemed as your signature

Title