Submit for Toddlers on the Move

Toddlers on the Move

Toddlers on the Move is a mobility device loan program for our youngest members.

Allow your toddler the mobility and independence to explore their world!

Eligibility: Family must reside in Wisconsin, and must remain in Wisconsin for the entirety of the loan. Child must have primary diagnosis of Spina Bifida and be between the ages of 9 months and 3 years old.
Enrollment Steps: Click **HERE** to read the Toddlers on the Move Loan and Terms of Agreement. You can download, save and print it for your records.
Click **HERE** to read the Agreement to Borrow Equipment and Release of Liability. You can download, save and print it for your records.
Complete the online form below and click submit. The form includes verification that you’ve read and understand the 2 documents linked above.
Once you click submit, our staff will contact you via email within 5 business days letting you know if a zip zac is available. If one is available, the next step is for you to submit a letter from a medical professional or therapist stating your child’s diagnosis and verification that the zip zac mobility device is appropriate and meets the needs of the child. This can be post mailed or emailed to our office.
After returning the required paperwork, staff will contact you to arrange a time for you to get the zip zac. Meetings can take place in your home, at our office or at a clinic. If meeting in person isn’t possible, SBWIS will ship a zip zac device to a toddler anywhere in Wisconsin. The $160.00 cash deposit is due at this meeting.
This process takes about 2 weeks and the term of the loan is intended for up to 3 years depending on demand. Thank you for your interest and we can’t wait to see your Toddler on the Move!

Name of child with SB *

First Name

Last Name

Date of birth *

Gender male or female *

Size zip zac for my child (small red or large blue) *

Name of primary parent/guardian *

First Name

Last Name

Complete mailing address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Wisconsin County of Residence *

Mobile Phone number *

Email *

Name of secondary person responsible as borrower of this equipment *

First Name

Last Name

Phone

(###)

###

####

Is there another way SBWIS could help you or your family member with spina bifida related needs? *

Your check in the box below indicates your agreement and understanding of our program. *

Yes, I agree that as the borrower, I have read and understand the terms and conditions document provided and I am checking this knowingly and voluntarily.

Yes, I agree that as the borrower, I understand that the equipment must be returned if I move out of state.

Yes, I agree that as the borrower, I must not loan the equipment to other individuals or organizations.

I understand it is my responsibility to provide photos and testimonials to SBWIS 4 times per year for use on their Facebook page and website.

I understand that it is my responsibility to return the equipment to SBWIS.

I agree to providing $160.00 cash to SBWIS, fully refundable when the equipment if this contract is upheld 100%.

As the borrower, my typed name is my legal signature verifying that the information I'm submitting is true. *

First Name

Last Name

Date of submission *

Select *

The material used to make the zip zac is a dense foam that absorbs odors, like smoke. We have 1 red and 1 blue zip zac dedicated to loan to smoking households.

How do you keep in touch with SBWIS? *

Checking the website

Following Facebook posts

Newsletter postcard

Email blasts

Thank you! Our staff will contact you within 5 business days about your Toddlers on the Move request.

Thank you for your interest in our Toddlers on the Move program. Completion of the paperwork does not guarantee a zip zac for your child. We will work with you until a zip zac becomes available. We are pleased to have this beneficial program and would like to thank our donors for making this possible!

Spina Bifida Wisconsin, Ltd enhances the lives of Wisconsin's families affected by Spina Bifida by providing resources, peer support and social events in our community. We strive to raise other's awareness about the unique needs of people with Spina Bifida. We are ambassadors, peers and educators changing the lives of those we serve.

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(414) 607-9061 EMAIL: sbwis@sbwis.org
830 N 109th Street Suite 6 Wauwatosa, WI 53226