Application Form

Application number

What would you like to apply for?* This field is required.*please only select one option

Hand

Finger

Arm

Sport/instrument/activity adapter ie skipping rope adapter

Please indicate which option best describes your condition* This field is required.FOR HAND *Though we are able to help a wide range of disabilities at this stage the kinetic hand does not function with neurological disorders that affect the limbs. For example, Cerebral Palsy, stroke, brain tumors or autoimmune diseases.

I have partially formed hand/s with a functioning wrist, ie. the wrist must have at least some movement upwards or downwards and the hand must be partially formed.

I have a partially formed hand without a functioning wrist, ie no wrist movement at all. *Currently we do not have a suitable device but please keep me on a waiting list for future developments.

I have full hands & fingers with limited or no mobility. *Currently we do not have a suitable device but please keep me on a waiting list for future developments.

Please ensure your partial finger/s is within the illustrated dimensions below.

Please indicate which option best describes your condition* This field is required.Finger **Though we are able to help a wide range of limb differences and disabilities at this stage the Kinetic Hand does not function with neurological disorders that affect the limbs. For example, Cerebral Palsy, stroke, brain tumors or autoimmune diseases.

Yes my partial finger/s are within the illustrated dimensions on the photo.

I have missing finger/s, but outside of the lines in the photo *Currently we do not have a suitable device but please keep me on a waiting list for future developments.

I have fingers with limited or no mobility. *Currently we do not have a suitable device but please keep me on a waiting list for future developments.

I am interested in getting an Arm* This field is required.We are currently developing a bionic arm however this will initially ONLY BE SUITABLE FOR LIMB DIFFERENCES BELOW THE ELBOW. The arm will not function with neurological disorders that affect the limbs. For example, Cerebral Palsy, stroke, brain tumors or autoimmune diseases. Please keep an eye on our website for development status.

I have a trans-radial/below elbow limb difference. *Currently we do not have a suitable device but please keep me on a waiting list for future developments.

Is your Recipient over 4 years old?* This field is required.if "No" please continue the application process and we will keep your details on our database for future developments in producing smaller hands and fingers.

YESNO

Which device would you like?* This field is required.You can make multiple requests.

3D Hand (Right)

3D Hand (Left)

Which device would you like?* This field is required.

Kinetic Finger

Kinetic Fingers(multiple)

This is a video guide for how to take the four measurement photos required to scale your Kinetic Finger to the correct size. Please take the time to watch the video before photos are uploaded in the next step.

This is a video guide for how to take the four measurement photos required to scale your 3D hand to the correct size. Please take to time to watch the video, as well as refer to the photos on the following pages before uploading your photos in the next steps.

Please take a photo of the affected hand by placing a ruler along the edge of a table. Mark a line across the wrist like shown. Make sure that the top of the hand and forearm are level with the top of the table to ensure that correct scaling is taken.

Please take a photo of the un-affected hand by placing a ruler along the edge of a table. Make sure that the top of the hand and forearm are level with the top of the table to ensure that correct scaling is taken.

Please take a photo from the side of the affected hand, deflecting the wrist upwards to show us the maximum angle of movement. This will help us to tune the open position of the 3D Hand.

Please take a photo from the side of the affected hand, deflecting the wrist downwards to show us the maximum angle of movement. This will help us to tune the closed position of the 3D Hand.

Measurement Photos* This field is required.Please upload all four of your measurement photos. Before you take the photos, read the instructions carefully. It is extremely important you do the measurement correctly to ensure that we scale the hand to the correct size.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Which colour/s would you like? (Colour choices are available for Kinetic Hands and Kinetic Fingers only. Colour choice is subject to availability)* This field is required.

Red

Pink

Green

Yellow

Silver

Black

Purple

Blue

Colour changing Green to Yellow

Carbon Black

Gold

White

Glow in the dark White to Purple

Leave the colour up to us!

Navy Blue

Would you like another assistive device?We offer the following attachments that you are able to receive. Please choose which device/s you would like.

Skipping Rope Adapter (can be used for multiple purposes like drums, brushes etc)

Tennis Ball Serving Aid (compatible with the Skipping Rope Adapter)

Piano Attachment (for left hand differences only, compatible with the Skipping Rope Adapter)

No thanks!

Do you wish us to consider developing another type of device or adapter for you that we currently don't provide? (upper limb only)This is an optional question. If no, please skip.

Recipient's history of using an assistive device in the past.Answers to these questions are optional and will not affect our willingness to make you a device. However, we may be able to better understand your condition and make recommendations based on your answers to get you further support.

Recipient's Name* This field is required.

First Name

Last Name

Recipients Date of Birth* This field is required.

Date

Recipient's Age* This field is required.

Age

Please upload a selfie! We would like to show our volunteers who we are making a device for! This is optional only. :-)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Postal Address* This field is required.(We aren't able to send to North America)

Street Address

City

State / Province

Postal / Zip Code

Country

Contact Person's Name* This field is required.

First Name

Last Name

Relationship to Recipient* This field is required.

Contact Person's Email* This field is required.

example@example.com

Contact Person's Phone Number* This field is required.

Area Code

Phone Number

Terms and Conditions* This field is required.By accepting any design, plan, component or assembly from Free 3D Hands Ltd, I understand and agree that any such information, devices or materials provided by any individual associated with the design team is presented as is without representation or warranties of any kind, express or implied, and is intended to be a free gift for the sole purpose of evaluating various design iterations, ideas and modifications. Devices must be used for only light tasks such as picking and placing of small objects, and not for any tasks that could be considered dangerous. All devices are for trial purposes only. I understand that such devices are intended to benefit certain individuals with specific limb differences and disabilities and are not intended, and shall not be used, for commercial use. I further understand and agree that any individual associated with Free 3D Hands Ltd shall not be liable for any injuries or damages resulting from the use of any of the information, devices or materials related to Free 3D Hands Ltd. I understand and agree that these devices are experimental, are not classified as medical devices, and are for evaluation purposes only.I agree that in some cases, these devices will not be appropriate for each individual, and consultation with medical professionals and occupational therapists must be sought and obtained before use.I understand that waiting times may vary due to existing demand, complexity and need for individual customisation of devices.Some devices can be made quicker than others, so it is not necessarily a first in first served basis.I understand that all information provided above is strictly confidential, and any release of photographs and information for promotional purposes must be requested and agreed to in writing beforehand. We also cannot guarantee that we can make you a device, pending evaluation of your physical circumstances and our ability to design and manufacture an adequate solution.We cannot commit to an exact time frame at this stage however we once again ask for your patience and strongly encourage you to follow our progress on social media at www.facebook.com/free3dhands for updates on production and new designs. By ticking the checkbox below, you are agreeing that you have read, understand and agree to all of the terms and conditions. Only in agreeance with these terms are we able to provide you with a device.

Yes,I have read,understand and agree to all of the terms and conditions.

Any questions or comments? All devices are Free. Unfortunately, We can't tell you exactly when we can provide your devices. Our devices are all custom make for each individual taking varying amounts of time. We thank you for your patience and we will be in contact with you as soon as possible.

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