Copy of Non-occupied Adaptive Equipment Study

Adapy Eligibility Survey

Participation Instructions:

To get started, simply complete the short survey on this page. Your responses will help us determine if you qualify for a free, subsidized, or reduced-cost installation of the Adapy system. The survey takes just a few minutes to complete. Once submitted, a member of our team will review your information and contact you to answer any questions, confirm eligibility, and guide you through the next steps for installation. There’s no obligation—just a quick way to see if Adapy is right for you.

Enter your email address

Enter your first name

Enter your last name

Are you a U.S Veteran?

Yes

If yes, what type of veteran status applies to you? (Multiple Choice)

Service-Connected Disabled Veteran

Recently Separated Veteran

Active Duty Wartime or Campaign Badge Veteran

Armed Forces Service Medal Veteran

Other

Unsure

Are you currently working with any of the following services? (Check all that apply)

Vocational Rehabilitation (State-level)

Workforce Services

Department of Veterans Affairs (VA)

Occupational Therapist

Physical Therapist

Case Manager or Social Worker

None of the above

If yes, please provide the name and contact information (if known) of your representative, therapist, or counselor:

What type of disability do you have?

Paraplegia

Quadriplegia

Amputation

Neuromuscular Disorder (e.g., MS, ALS)

Traumatic Brain Injury (TBI)

Other

Do you use a wheelchair?

Yes - Manual

Yes - Power

Which adaptive equipment do you currently use in your vehicle or mobility setup? (Check all that apply)

Bruno PUL-1100 Lift

Transfer Seat (e.g., Asento XL, Evo)

Harmar Lift

BraunAbility Equipment

Sure-Grip Driving Controls

Truck bed Topper

EZ Lock or Q'Straint Docking

Tech Access

Yes - iPhone

Yes - Android

Why are you interested in participating in this study, and how do you think Adapy could benefit you?

Enter your phone number

This study is for United States only.

We use Brevo as our marketing platform. By submitting this form you agree that the personal data you provided will be transferred to Brevo for processing in accordance with Brevo's Privacy Policy.

Consent & Opt-In Statement

Check Here

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that Adapy, Inc. may contact me regarding my eligibility for the study, product installation, or to collect feedback related to the Adapy Smart Mobility System. I give my consent to be contacted via email, phone, or text message for purposes related to this study or future updates about adaptive mobility solutions. I understand that my participation is voluntary and that I may opt out at any time.