Access By Skip Questionnaire

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Access By Skip Questionnaire

Name:
Email Address:
Home Phone:
Cell Phone:
Scooter or Wheelchair:	Scooter Wheelchair Other None
If other, what do you have?
Please describe the scooter or wheelchair. (Brand, serial number, features, etc.)
Are you looking to modify a vehcile? If yes, what type?
Desired vehicle capabilities/features. Please check all that apply.	You can drive You can be passenger You can sit in the center of the vehcile Hand controls Turning Automotive Seating EZ Lock Kneeling capabilities (mini vans only)
Other capabilities: Please specify.
Is there something else that Access By Skip can do to provide you with a more mobile and independent lifestyle?

Wheelchair Lifts

Hand Controls

Stair Lifts