Sport Wheelchair Rental Form

School Name*

Educational Stage*

Range of Grades in School*

School District*

NOTE: We will be in the Peel/Halton regions from September to December and will visit all other districts from January to June.

Contact Name*

Position*

School Address*

City*

Postal Code*

Email*

Phone Number*

What is the total number of students at your school?*

How did you learn about our program?*

Do you have any students at your school that have a physical disability (i.e., multiple sclerosis, cerebral palsy, use a wheelchair or a walker, amputee, etc.)? *

Yes

No

Unsure

If yes, approximately how many students at your school have a physical disability?

Is your school wheelchair accessible?*

Yes

No

Please indicate at least 3 potential dates that work best for your school to schedule a presentation on.

Elementary and Middle schools can only choose Tuesday or Wednesdays Secondary schools can choose Monday, Tuesday, or Friday

Date Option 1*

Date Option 2*

Date Option 3*

Please indicate what time you would like to have your presentation. *

After receiving a presentation, when would you like to begin your rental week? Please choose at least 3 potential weeks that work for your schedule.

Elementary and Middle schools can only choose Tuesday or Wednesdays Secondary schools can choose Monday, Tuesday, or Friday

Date Option 1*

Date Option 2*

Date Option 3*

A Sport Wheelchair Rental Week will cost $700. How would you like to pay?*

Cheque

Credit

The cheque could be picked up by our team on your presentation date. The cheque should be made out to the ‘Ontario Para Network’. If need be, you could mail out the payment to us at:Ontario Para Network100 Sunrise Avenue – Suite 101Toronto, Ontario M4A 1B3

Please indicate at least 3 potential dates that work best for your school to schedule a presentation on.

After receiving a presentation, when would you like to begin your rental week? Please choose at least 3 potential weeks that work for your schedule.

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