Special Needs Solutions

Lap Pads

Fill in the necessary measurements and information below, and simply "Submit" it to us. If you have any questions, feel free to call or email us. We will be in touch.

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Person recommending equipment

First Name

Last Name

Your Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Client's Name

First Name

Last Name

Client's Birthdate

Pad Weight

1 pound

2 pounds

3 pounds

4 pounds

5 pounds

other (note in "Special Instructions")

Special Instructions

Anything else you want us to know

Lap Pads

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special Needs Solutions is a tax-exempt 501(C)(3) nonprofit organization. Your gift is tax-deductible as allowed by law.