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Designing & building assistive equipment
for people with disabilities
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View our products that help people who may have very specific or complex needs.
Accessible Aviation
Accessible Music
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Switches and joysticks
iPad® accessories
Device mounting
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Positioning & support
Bugzi Loan Scheme
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Accessible Aviation
Mobility Prodcuts
iPad Accessories
Switch Adapted Toys
Accessible Music
Switches & Joysticks
Device mounting
Positioning and support
Bugzi Loan Scheme
About
Donate
Contact
Home
Shop Online
Accessible Aviation
Mobility Prodcuts
iPad Accessories
Switch Adapted Toys
Accessible Music
Switches & Joysticks
Device mounting
Positioning and support
Bugzi Loan Scheme
About
Donate
Contact
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Online Bugzi Application
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Online Bugzi Application
Online Bugzi Application
2020-10-11T21:41:23+01:00
Step
1
of
9
- Child's Details
11%
Child's Details
Preferred assessment centre
*
Aylesbury
Belfast
Birmingham
Truro
St Helens
Thetford
Derby
Leeds
Carshalton
Glasgow
Newcastle
Rhyl (North Wales)
Cardiff
Welwyn Garden City
Child’s Full Name
*
Date of Birth
*
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Gender
*
Male
Female
Home Address
*
Street Address
Town/City
County
Postcode
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
*
YES
NO
Their Name
*
Their contact number
*
Their email address
*
Child’s Professional
*
Job title
*
Phone
*
Email
*
Seat Measurements
SEATING DIMENSION (cm/kg)
Seat Depth in CM
*
See image arrow D
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)
Seat Measurements
Seat Width (E) in CM
*
See image arrow E
Seat Measurements
Shoulder height (B) in CM
*
See image arrow B
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
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?
*
Using Bugzi
How many days a week do you anticipate Bugzi will be used?
*
1 -2
3 - 5
6 - 7
And for how many minutes on those days?
*
10 - 20
30 - 40
50 - 60
60+
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 following
You 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.
Asian Bangladeshi
Asian Indian
Asian Other
Asian Pakistani
Black Afican
Black Caribbean
Black Other
Chinese
Mixed other
Mixed White + Asian
Mixed White + Black African
Mixed
Mixed White + Black Caribbean
White British
White Irish
White Other
Ethic Other
Declined to comment
Other
Please specify ethic origin
*
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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
Name
This field is for validation purposes and should be left unchanged.
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