Bugzi Application Form

Step 1 of 5

20%

Name

This field is for validation purposes and should be left unchanged.

We recommend the support of your child’s health professional (e.g. Occupational Therapist, Physiotherapist) to get the most from using Bugzi.

In order to provide your child with Bugzi we will share your application form with the centre you select. They will hold your data and will have their own privacy notice that you can ask to see.

Our privacy policy is available on our website or on request which outlines how we use and store your data.

We may take an image of your child in Bugzi at assessment for our clinical records. We will not share this image unless you give us permission to do so.

You must complete all sections of this form.

Bugzi is for indoor use (or limited outdoor use where dry and level) .

The maximum weight of child must not exceed 25kg.

Bugzi must be used in accordance with instructions provided.

Bugzi must only be used by the child for whom it is prescribed.

Which assessment centre do you wish to attend?(Required)

Birmingham

Cardiff

Chester

Glasgow

Leeds

Surrey

Thetford

Truro/Exeter

Welwyn Garden

Child's full name(Required)

First Middle Last

Gender(Required)

Female

Male

Date of birth(Required)

School Squad

Home address(Required)

Street Address Address Line 2 City Postcode

Primary contact(Required)

First Middle Last

Secondary contact

First Middle Last

Relationship to child (primary)(Required)

Relationship to child (secondary)

Email (primary)(Required)

Email (secondary)

Phone (primary)(Required)

Phone (secondary)

Dimensions (cm)

Seat Depth (A)(Required)

Footrest height (B)(Required)

Seat Width (C)(Required)

Backrest Height (D)(Required)

Thoracic pad height (E)(Required)

Weight in kg(Required)

Health professional(Required)

First Middle Last

Job title(Required)

Email(Required)

Phone

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?(Required)

How does your child move their arms, legs and head, as well as their whole body?(Required)

How does your child express themselves? Do they talk, use signing, use pictures, use special sounds?(Required)

How does your child use electronic controls in other activities? e.g. switches, joysticks, tablets, phone(Required)

What are the best positions for the controls they use?(Required)

How many days a week do you anticipate Bugzi will be used?(Required)

1-2

3-5

6-7

And for how many minutes on those days?(Required)

10+

30+

50+

60+

What do you hope your child will learn by using Bugzi?(Required)

What impact do you think Bugzi may have on your child’s participation in their family, school and social life?(Required)

Where is Bugzi going to be used? e.g. Home, School, etc(Required)

How will you safeguard against hazards? e.g. Downward steps, tables, shelves, floor lamps, etc.(Required)

Where did you hear about Bugzi?

Terms & Conditions

You must attend one of our partner centres for initial assessment.

A £100 returnable deposit must be paid online prior to signing the loan agreement on day of assessment.

A review will take place initially via phone in approx. 3 months and then by post or phone yearly, where you will be asked to provide information on your child’s use of Bugzi. (We may not be able to guarantee continued loan if this is not completed).

You are responsible for returning Bugzi and all accessories to one of our assessment centres when it is no longer required. Cerebra can arrange a courier collection from your home but reserve the right to make a charge to cover postage costs for this.

If adjustment or accessories are required during the loan period, it is your responsibility to take the child to your local assessment centre.

As full attention to the child being assessed is needed, it is advisable not to bring siblings to the assessment. If siblings are coming a minimum of two adults should attend to enable supervision. If this is not possible, it is your responsibility to inform the centre in advance.

An image of your child in the Bugzi may be taken and stored for our medical files. We will not be sharing this image with anyone.

By signing this application, you agree to give permission to share the information on this form with your named professional.

Please tick to confirm that you have understood the above terms and conditions of this application.(Required)

I understand the terms & conditions.

On occasion, supporters of the Bugzi Loan Scheme request information or an image of a child in Bugzi.

I would be happy to discuss giving consent at the assessment.

Cerebra is committed to protecting and respecting your privacy

Please tick to confirm that you agree to our privacy policy regarding how we use your information. The information you provide will be used for Cerebra only.(Required)

I agree to the privacy policy

We'd like to send you occasional updates about our work, campaigns and fundraising. (You can unsubscribe from our emails at any time.)

I would like to opt-out of all electronic mail updates.

CAPTCHA

Make a Donation

Home
Get Advice and Support
Bugzi Application Form

Bugzi Application Form

Home
Get Advice and Support
Bugzi Application Form

Bugzi Application Form

Dimensions (cm)

Terms & Conditions

Cerebra is committed to protecting and respecting your privacy

Contact Us

Make a Donation

HomeGet Advice and SupportBugzi Application Form

Bugzi Application Form

HomeGet Advice and SupportBugzi Application Form

Bugzi Application Form

Dimensions (cm)

Terms & Conditions

Cerebra is committed to protecting and respecting your privacy

Contact Us

Home
Get Advice and Support
Bugzi Application Form

Home
Get Advice and Support
Bugzi Application Form