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Wizzybug loan scheme application
A child in their wizzybug
Thank you for your interest in Wizzybug! This form will help us determine if a Wizzybug is right for your child. It should take approximately 20 minutes to complete, and you will need to know your child's weight and height.

By completing this form, you agree to the terms outlined in Designability’s data policy.

For help completing your application please email info@designability.org.uk or call 01225 824103



This number may have automatically populated, if not and if we have provided one, please enter the enquiry number from our correspondence. Otherwise you can leave this blank.
Representation





PARENT / GUARDIAN





Please enter your full mobile phone number (ie, 07753753731).

Please enter your home phone number with your UK area code.





HOW DID YOU HEAR ABOUT THE WIZZYBUG LOAN SCHEME?







ABOUT YOUR CHILD



*Wizzybug is best suited to children aged between 14 months and 5 years old, although this can vary depending on the child.




Add relevant information regarding: vision, hearing, non-oral feeding, seizures, choking, aspiration

If your child is over 18kg, please be aware that your application may be declined as Wizzybug may be too small. Our maximum weight limit is 20kg and any applications over this weight will be declined.



Wizzybug has a flat headrest and therefore children must be able to hold their head up independently to safely use it. 

If your child has difficulty with this, please do not submit your application until you have discussed the suitability of wizzybug with your local therapist or contacted us directly.

Please refer to our User requirements guidlines for further information

Your Wizzybug Appointment
The appointment sites for Wizzybug handovers are Bath, Leeds and Larne (Northern Ireland). ​
We will always try to accommodate your preferred site, however appointment availability may vary and we may ask you to attend another where necessary.
Please choose your preferred handover site:

General Contact and Privacy Consent
Please help us to tell other families about the Wizzybug Loan Scheme by sharing your experiences.





Access Fund
Wizzybug is free to all families.

For support to cover the cost of attending your Wizzybug appointment, you can apply to the Access Fund.



CHILD'S THERAPIST (IF APPLICABLE)











BODY MEASUREMENTS (IN SITTING)

Please refer to the User Requirements and How To Measure Your Child documents before completing this section.


(Note: If the measurements of your child are currently less than the minimum allowed, please apply to us again as soon as your child reaches the required minimum measurements)

Measurements in sitting
Please complete the measurements, referring to the image above if needed.

0 - 24.5 cm

18 - 28 cm

26 - 38 cm

18 - 30 cm

0 - 18 kg

e.g. oxygen, Bipap, Cpap, suctioning, NG tube etc.
SEATING CONSIDERATIONS
In relation to the headings below, please describe any relevant aspects such as contractures, muscle weakness, dislocation, tone, shortened limbs etc. that may affect sitting in the Wizzybug.



e.g. mobility aids, specialist head support, specialist seating, orthotic supports, brace, lycra suit, sleep system
HAND, ARM & SHOULDER FUNCTION
Please describe the following:


e.g. range of movement / reach, tone, grasp & release, contracture's, muscle strength

COGNITION

e.g. cause and effect, following simple instructions

Inclusion Section
We want to ensure every child who could benefit from a Wizzybug knows about them. By providing some additional information about you, it helps us check we are reaching as many families as possible. This information is optional, will be anonymised and will only be used for evaluation and monitoring purposes.
ABOUT YOUR CHILD






ABOUT YOUR FAMILY - DISABILITY
Disability is defined by the Equality Act 2010 as a person who has a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.


ABOUT YOUR FAMILY - FINANCIAL CIRCUMSTANCES


You have indicated that your child does not have head control. Please read our User requirements before submitting this form. Wizzybug has a flat headrest and therefore children must be able to hold their head up independently to safely use it.
Please select "I consent" to continue submitting the form
You have not indicated if your child has head control on page 3. Please fill in this information before submitting the form.
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For help completing your application, please email info@designability.org.uk or view our contact page by clicking this link.
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