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May 2014 Kid's ROCK TM Size 3 Order Form Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING INFORMATION Provider Acct #: PO#: Provider: Ship To: Provider Contact: Attention: Prov. Address: Address: Provider City: ST: ZIP: Address: Provider Phone: ( ) Fax: ( ) Ship To City: ST: ZIP: Ship To Phone: ( ) Fax: ( ) Confirmation Email: DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. HCPCS codes should not be considered as legal advice. All prices MEASUREMENT WORKSHEET Kids ROCK Size 3 chair, Tilt-in-Space Mark For: Age: Height: ft. in. Includes: Tilt in space, non-dynamic, mobility base, Silver metallic frame color, standard configuration. Weight: lbs. E1233 ROCK Chair - Size 3 $2,950.00 E1161 ROCK Chair - Size 3 $2,950.00 Transit Option 3222-5100 Seating System and 3222-5200 Back System Required for ISO 7176-19 compliance.transit Option must be factory installed and is not retrofitable. Transit Option $200.00 Upholstery Color Upholstery Color applies to: back cushions lateral pelvic/thigh supports Black/Sport Mesh Vibrant Red/Black/Sport Mesh Purple/Black/Sport Mesh Figure 1 - Client Measurements Teal/Black/Sport Mesh A. Sitting Depth B. Trunk Depth C. Trunk Width D. Hip Width E. Top of Shoulder to Seat F. Lower Leg Length Reaction Dynamic Seating Requires 3223-5800 Angle Adjustable Leg Rests E2295 REACTION Dynamic Component $895.00 Upper Body Spring Selections Soft - Pair Medium - Pair Hard - Pair No Springs Page 1 of 7

Front Rigging 3223-5800 Required with REACTION Dynamic Seating System. 90 Fixed Front Rigging E0990 Angle Adjustable Leg Rest Soft - Pair Medium - Pair Hard - Pair No Springs $225.00 3223-5800 Required when ordering KRC302 Active Seating Accessory. Knee angle adj. 18 incr. w/press of button. allows active movement of lower leg. Lower Body Spring Selections Foot Plate Requires Front Rigging Selection 90 Fixed Foot Plate K0040 Quick Angle Adj. Flip-Up Foot Plate $165.00-18 to +45 Dorsal/Plantar Flexion. 8 Positions. Kids ROCK 3 Adjustable Depth Seating System K0108 14-20" Adj. Depth Seat Pan $195.00 Kids UP LifeForm Contoured Seat Cushion Selections Seat Cushions Incl: 2 Positioning Wedges, Abductor Wedge; Black Mesh Cover Ischial Insert Selection Required E2294 14" Width, 14-17" Depth $365.00 E2294 17" Width, 14"-17" Depth $365.00 Open Cell Foam E2294 17" Width, 17"- 20" Depth $365.00 K0108 Soft Memory Foam $50.00 K0108 Medium Memory Foam $50.00 Kids UP LifeForm Seating System Accessories Extra Positioning Wedges (4) Pressure Relief Layer - Soft Memory Foam (17" x 20" x 1/2") $35.00 $60.00 Wedge for Seat Cushion (14" x 8" x 1") Wedge for Seat Cushion (17" x 9" x 1") $40.00 $40.00 Synergy Seat Cushion Options Synergy Solution Cushion 14"x12" Synergy Solution Cushion 14"x14" Synergy Solution Cushion 14"x16" Synergy Solution Cushion 14"x18" Synergy Solution Cushion 16"x16" Synergy Solution Cushion 16"x17" Synergy Solution Cushion 16"x18" Synergy Solution Cushion 16"x19" Synergy Solution Cushion 16"x20" Synergy Solution Cushion 17"x16" Page 2 of 7

Synergy Seat Cushion Options-(cont.) Synergy Solution Cushion 17"x17" Synergy Solution Cushion 17"x18" Synergy Solution Cushion 17"x19" Synergy Solution Cushion 17"x20" Synergy Solution 1 Seat Cushion 14"x14" W/Gel Layer Synergy Solution 1 Seat Cushion 14"x16" W/Gel Layer Synergy Solution 1 Seat Cushion 14"x18" W/Gel Layer Synergy Solution 1 Seat Cushion 16"x16" W/Gel Layer Synergy Solution 1 Seat Cushion 16"x18" W/Gel Layer Synergy Solution 1 Seat Cushion 16"x20" W/Gel Layer Synergy Solution 1 Seat Cushion 17"x17" W/Gel Layer Synergy Solution 1 Seat Cushion 17"x19" W/Gel Layer Kids ROCK 3 Back System Options E2293 Configurable, Contoured, Adjustable Height Solid I-Back System $585.00 E2293 Configurable, Contoured, Adjustable Height Solid Full-Width Back System $585.00 Back Canes Only. (Not ISO 7176-19 Compliant) Kids UP Lifeform Back Cushion Options Select 1 if 3222-5200 is Selected. Back Cushions include contouring wedges and lumbar support 18"-23" Contoured Back Cushion. (I-Back) 22"-26"" Contoured Back Cushion. (I-Back) 18"-23" Contoured Full Width Back Cushion. (Black Color Only) 22"-26"" Contoured Full Width Back Cushion. (Black Color Only) Omit Back Cushion Less $135.00 Block Letters Back Cushion Embroidery (Emboridery is applied to colored panel) Script Letters Inscription, Please place one letter per box Blue Thread Red Thread Black Thread Green Thread Purple Thread White Thread Basic Fixed Height Armrest 12" Thin Profile - Pair Armrest Options E0973 Adjustable Height Armrest $195.00 Thin Profile Pad - Pair E0973 Adjustable Height Armrest $195.00 Armrests with * not for use with 24" Rear Wheels Full Length Pad - Pair * Page 3 of 7

Tray E0950 Upper Extremity Positioning Platform Color $128.00 - Clear E0950 Upper Extremity Positioning Platform Color $128.00 - Gray Angle/Depth Adj. Support Hardware - Req. for all trays $144.00 Rear Wheel Options 18" Composite Rear Wheels 24" Composite Rear Wheels. Requires 3223-5600 Rear Tire Options Full Polyurethane w/treads Pneumatic E2213 Pneumatic w/airless Inserts (Not Available w/ 18" Wheels) $88.00 Rear Anti-Tips E0971 Rear Anti-Tips with Wheels (Pair) $135.00 Hand Rims 24" Wheel Axle Options Available with 24" Rear Wheels Chrome Hand Rims Plastic Coated Hand Rim Upgrade (Not Avail. w/18" Wheels) Omit Hand Rims $92.00 Required when ordering 24" Rear wheels. Adj. Position Axle System $122.00 Attendant Wheel Lock Option Requires 18" rear wheels Attendant Wheel Lock $100.00 Casters 5" x 1.5" Poly Casters 8" x 2" Poly Casters Lateral Pelvic/Thigh Supports E0956 Left Pelvic/Thigh Support Pkg. $120.00 E0956 Right Pelvic/Thigh Support Pkg. $120.00 Page 4 of 7

Lifeform Anterior Pelvic Positioning Belts Medial 4-point pelvic positioning belt recommended with REACTION seating. Positioning belts not for use as a occupant restraint during transit in a motor vehicle. E0978 LifeForm 2-point 1" Metal PB Buckle, 3.5" $88.00 E0978 LifeForm 2-point 1.5" Metal PB Buckle, $90.00 pads 6.5" pads E0978 LifeForm Medial 4-point 1" Metal PB $110.00 E0978 Buckle, 3.5" pads E0978 LifeForm Medial 4-point 1" Metal PB $110.00 Buckle, 4.5" pads LifeForm Medial 4-point 1.5" Metal PB Buckle, 6.5" pads $110.00 Lifeform Anterior Trunk Support Anterior Trunk Supports not for use as a occupant restraint during transit in a motor vehicle. LifeForm Contoured Dynamic LifeForm Zipper Opening Dynamic E0960 Contoured - S LifeForm Contoured Structured E0960 Contoured Structured - S E0960 Zipper Opening - S E0960 Zipper Opening - M E0960 Zipper Opening - L LifeForm Zipper Opening Structured E0960 Structured Zipper Opening - S E0960 Structured Zipper Opening - M E0960 Structured Zipper Opening - L Lifeform Swing-Away Abductor Hardware and Pads 4-way stretch cover included with Lifeform Abductor pads. E1028 ROCK 3 S/A Abduct. Hardware $220.00 E0957 E0957 E0957 Small Wedge(2"-3"W x 4"L x 3"D) Med. Wedge (2"-4.5" x 5"L x 3"D) Lg. Wedge (3"-5" x 5"L x 4"D) $140.00 $140.00 $140.00 Lifeform Headrest and Support Hardware E0955 8" Curved Oval Pad $195.00 E1028 E0955 10" Curved Oval Pad $195.00 LifeForm Removable Headrest Mounting Hardware (Required for all Headrest Options) E0955 14" Curved Oval Pad $195.00 Universal Head Rest Mount Plate Only* $50.00 E0955 Narrow Adjustable Arc Pad $280.00 E0955 Standard Adjustable Arc Pad $280.00 *Accomodates several other manufacturers headrests. Call for details. $215.00 Stealth Hard Side Foot Stabilizers Lifeform Ankle and Foot Positioning K0108 Small, Pair, Left and Right $166.00 K0108 Left - Medium - 4"W K0108 Medium, Pair, Left and Right $166.00 K0108 Right - Medium - 4"W K0108 Large, Pair, Left and Right $166.00 K0108 Left - Large - 5"W LifeForm Ankle Hugger Foot Stabilizers K0108 Right - Large - 5"W Page 5 of 7

Lifeform Swing Away Lateral Support Hardware Choose your bracket and CURVED pad size Choose your bracket and PLANAR pad size E0956 Left 1.5" pediatric bracket lateral thoracic $110.00 E0956 Left 1.5" pediatric bracket lateral thoracic $110.00 support package, Curved Pad support package, Planar Pad E0956 Right 1.5" pediatric bracket lateral thoracic $110.00 E0956 Right 1.5" pediatric bracket lateral thoracic $110.00 support package, Curved Pad support package, Planar Pad E0956 Left 2" bracket lateral thoracic support $135.00 E0956 Left 2" bracket lateral thoracic support $135.00 package, Curved Pad package, Planar Pad E0956 Right 2" bracket lateral thoracic support $135.00 E0956 Right 2" bracket lateral thoracic support $135.00 package, Curved Pad package, Planar Pad Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose Swing-Away Hardware (required) Choose Swing-Away Hardware (required) Requires 3610-3110, 3120, 3210, 3220. Requires 3610-3110, 3120, 3210, 3220. E1028 Left 1.5" DoubleSwing pediatric swingaway E1028 Left 1.5" DoubleSwing pediatric swing- away E1028 Right 1.5" DoubleSwing pediatric swingaway E1028 Right 1.5" DoubleSwing pediatric swing- away E1028 Left 2" DoubleSwing E1028 Left 2" DoubleSwing E1028 Right 2" DoubleSwing E1028 Right 2" DoubleSwing LifeForm 1.5"Swing-Away Width and Depth Ext.(optional) Options Available only with Swing-Away Hardware. Depth Ext. + 1", pediatric, Left Depth Ext. + 1", pediatric, Right Width Ext. + 1", pediatric, Left Width Ext. + 1", pediatric, Right LifeForm 2"Swing-Away Width and Depth Ext.(optional) Options Available only with Swing-Away Hardware. Depth Ext. + 1", 2" Brkt., Left Depth Ext. + 1", 2" Brkt., Right Width Ext. + 1", 2" Brkt., Left Width Ext. + 1", 2" Brkt., Right LifeForm Fixed Lateral Support Hardware Choose your bracket and CURVED pad size Choose your bracket and PLANAR pad size E0956 Left 1.5" fixed pediatric bracket lateral $110.00 E0956 Left 1.5" fixed pediatric bracket lateral $110.00 thoracic support package, Curved Pad thoracic support package, Planar Pad E0956 Right 1.5" fixed pediatric bracket lateral thoracic support package, Curved Pad $110.00 E0956 Right 1.5" fixed pediatric bracket lateral $110.00 thoracic support package, Planar Pad E0956 Left 2" fixed bracket lateral thoracic support $135.00 E0956 Left 2" fixed bracket lateral thoracic support $135.00 package, Curved Pad package, Planar Pad E0956 Right 2" fixed bracket lateral thoracic $135.00 E0956 Right 2" fixed bracket lateral thoracic $135.00 support package, Curved Pad support package, Planar Pad Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Page 6 of 7

Additional Support Accessories K0105 IV Support Pole E2208 Oxygen Tank Holder E1029 Ventilator Tray $370.00 for LTV Ventilator Series Only Requires 18" Rear Wheels Additional Support Accessories NOT tested with Transit. Must remove prior to tie down. E1029 Battery/Vent. Accessory Tray Requires 18" Rear Wheels (Does not include vent. mount for LTV) $295.00 Accessories Replacement Contoured Seat Cushion Covers E2619 14"w x 17"d Seat Cushion Cover Only $102.00 E2619 17"w x 17"d Seat Cushion Cover Only $102.00 E2619 17"w x 20"d Seat Cushion Cover Only $102.00 Underchair Cargo Tray (carries up to 10 lbs) Rock 3 Sunshade $290.00 Custom Notes: Page 7 of 7

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