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R*+@,0p,*00^0(+  0+$-w,,      Rehabilitative Aids for People Living with Disability: Order Form Name: ____________________________________ Phone Number: ____________________________ Address: __________________________________ Email Address: _____________________________  Please check off the item(s) that you would like your donation to go towards: (All prices are listed in Canadian dollars) Crutches and Calipers Elbow crutches $13.00 Armpit Crutches $15.00 Round caliper (child) $11.00 Round caliper (adult) $13.00 Drop Lock (child) $22.00 Drop Lock (adult) $29.50 Pseudo Joint (child) $44.50 Pseudo Joint (adult) $55.00 Orthopedic Shoes small $23.00 medium $29.50 large $44.50 Single Customized Shoe (for people with foot deformity) $36.00 Single Customized Shoe $55.00 (for people with leg length discrepancy etc.) Mobility Aids Standard Wheelchair $220.00 Tri-cycle Wheelchair $360.00 Child Walker $30.00 Adult Walker $55.00 Specialized Items for Cerebral Palsy Adaptive chair $51.50 Child stander $44.50 Adult stander $55.00 Splints Wrist/hand splint $15.00 Forearm splint $22.00 Lower limb splint (child) $33.00 Lower limb splint (adult) $73.50 Child size corset $55.00 Adult size corset $88.50 Special Needs Training Mother and child with Cerebral Palsy for 1 week (activities of daily living and general care) $55.00 Mobility Aid training and with therapeutic exercises $88.50 Home visit, home program and follow-up $22.00 Surgical costs (Pre and post transportation, surgical cost, rehabilitation and mobility equipment) Wrist reconstruction $330.00 (Due to burns, disease or trauma) Elbow surgery $275.00 Shoulder surgery $550.00 Hip and pelvis operations $662.00 Knee surgery $370.00 Ankle and foot surgery $405.00 Removal of growths, $550.00 cysts, myositis etc Osteomyelitis $550.00 I would like my donation of $_______ to go towards any equipment that is required  Payment methods Cash: Must be given directly to a member of the Kenya Working Group Cheques: Please make payable to the International Centre for Disability and Rehabilitation and send to: International Centre for Disability and Rehabilitation University of Toronto Rehabilitation Sciences Building 500 University Avenue Toronto, ON M5G 1V7 Tax receipts will be sent to all donations over $10.00 Please note: All efforts will be made to use the funds you donate towards the item(s) you have indicated. However, if necessary, funds may be relocated to other equipment, training or surgery for the clinic and rehabilitation services in Kenya. 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