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May 2014 Kids ROCK TM Size 2 Order Form Maximum Weight Capacity 115 lbs. 14"Wx16"Dx22"H 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: Provider 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 MEASUREMENT WORKSHEET Kids ROCK Size 2 chair, Tilt-in-Space Mark For: Age: Height: Weight: ft. in. lbs. Includes: Tilt in space, non-dynamic, mobility base, Silver metallic frame color, standard configuration. E1233 Kids ROCK Chair - Size 2 $2,650.00 Transit Option 3222-5100 Seating System and/or 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, calf protector Black Vibrant Red/Black Green/Black Pink/Black Blue/Black Figure 1 - Client Measurements A. Sitting Depth B. Trunk Depth C. Trunk Width D. Hip Width E. Top of Shoulder to Seat F. Lower Leg Length Reaction TM Dynamic Seating Requires 3222-5800 Angle Adjustable Leg Rests E2295 Kids Rock TM Active Component $695.00 Upper Body Springs Soft - Pair Medium - Pair Hard - Pair No Springs Page 1 of 7

Front Rigging 3222-5800 Required with REACTION System. Calf Protector included with all Front Rigging Option. 3222-5700 90 Fixed Front Rigging Lower Body Springs 3222-5800 E0990 Angle Adj. Elevating Leg Rest $225.00 3222-7310C 3222-7350C 3222-7380C 3222-7300 Soft - Pair Medium - Pair Hard - Pair No Springs Foot Plate K0040 Select Foot Plate Installation: Std(10.5-14".5 Leg Drop) Inverted(7.5-11" Leg Drop) Long(14"-16" Leg Drop) 90 Fixed Foot Plate Bolt Angle Adjustable Foot Plate ±8 Dorsal/Plantar Flexion; -8-0 - +8 K0040 Angle Adjust Flip Up Foot Plate $165.00 $140.00 K0040 Quick Angle Adj. Foot Plate $165.00-18 to +45 Dorsal/Plantar Flexion; 8 Positions; Easy Pull Adj. Kids ROCK 2 Adjustable Depth Seating System K0108 8-17" Adj. Depth Seat Pan Kids UP LifeForm Contoured Seat Cushion Selections Seat Cushions Incl: 2 Positioning Wedges, Abductor Wedge; Black Mesh Cover E2294 8"-11" Depth $365.00 Ischial Insert Selection Required Open Cell Foam E2294 11"-14" Depth $365.00 K0108 Soft Memory Foam $50.00 E2294 14"-17" Depth $365.00 K0108 Medium Memory Foam $50.00 Kids UP LifeForm Seating System Accessories Extra Positioning Wedges (4) Pressure Relief Layer - Sunmate (14" x 16" x 1/2") $35.00 $60.00 Wedge for Seat Cushion (14" x 8" x 1") $40.00 Synergy Seat Cushion Options E2607 Synergy Solution Cushion 14"x12" E2607 Synergy Solution Cushion 14"x14" E2607 Synergy Solution Cushion 14"x16" E2607 Synergy Solution Cushion 14"x18" E2607 Synergy Solution 1 Seat Cushion 14"x14" W/Gel Layer E2607 Synergy Solution 1 Seat Cushion 14"x16" W/Gel Layer E2607 Synergy Solution 1 Seat Cushion 14"x18" W/Gel Layer Back System Options E2293 Configurable, Contoured, Adjustable Height Solid I-Back System $585.00 Back Canes Only. (Not ISO 7176-19 Compliant) Page 2 of 7

Kids UP Lifeform Back Cushion Options Select 1 if 3222-5200 is Selected. Back Cushions include contouring wedges and lumbar support 12"-17" Contoured Back Cushion. (I-Back) 16"-22" Contoured Back Cushion. (I-Back) Omit Back Cushion Less Block Letters Back Cushion Embroidery (Emboridery is applied to colored panel) Inscription, Please place one letter per box Script Letters Blue Thread Red Thread Black Thread Green Thread Purple Thread White Thread Basic Fixed Height Armrest Thin Profile - Pair Fixed Height Armrest Desk Length Pad - Pair * $170.00 E0973 Adjustable Height Armrest Desk Length Pad - Pair * Armrest Options E0973 E0973 Adjustable Height Armrest Full Length Pad - Pair * Adjustable Height Armrest Thin Profile Pad - Pair Armrests with * not for use with 22" or 24" Rear Wheels Tray Options E0950 Upper Extremity Positioning Platform Color - Clear $128.00 E0950 Upper Extremity Positioning Platform Color - Gray $128.00 Angle/Depth Adj. Support Hardware - Req. for all trays $144.00 Rear Wheels 16" Composite Rear Wheels 24" Composite Rear Wheels (only avail. w/ 8" Casters). Requires 3222-5600 22" Composite Rear Wheels. Requires 3222-5600 Rear Tires E2213 Full Polyurethane w/treads Pneumatic Pneumatic w/airless Inserts $88.00 Hand Rims Chrome Hand Rims (Not Avail. With 16" Wheels) Available with 22" and 24" rear wheels only. K0108 Plastic Coated Hand Rim Upgrade (Not Avail. w/16" Wheels) $92.00 Omit Hand Rims Page 3 of 7

Rear Anti-Tips E0971 Rear Anti-Tips with Wheels 22"/24" Wheel Axle Options Attendant Wheel Lock Option Requires 16" rear wheels and 8" casters Adj. Position Axle System $122.00 Attendant Wheel Lock $100.00 Caster Options Seat pan to floor height is15.5" with5" caster, and 17.5" with 8" caster. 5" x 1.5" Poly 8" x 2" Poly Lateral Pelvic/Thigh Supports Left Pelvic/Thigh Support Pkg. $120.00 Right Pelvic/Thigh Support Pkg. $120.00 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, $88.00 3.5" pads E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 3.5" pads E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 4.5" pads E0978 LifeForm 2-point 1.5" Metal PB Buckle, $90.00 6.5" pads E0978 LifeForm Medial 4-point 1.5" Metal PB Buckle, 6.5" pads 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 - Early Intervention E0960 Zipper Opening - S E0960 Contoured - XS E0960 Zipper Opening - M E0960 Contoured - S E0960 Zipper Opening - L LifeForm Contoured Structured E0960 Contoured Structured - S 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. ROCK 2 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 LifeForm Removable Headrest Mounting Hardware $215.00 E0955 10" Curved Oval Pad (Required for all Headrest Options) E0955 14" Curved Oval Pad Universal Head Rest Mount Plate Only* $50.00 E0955 Narrow Adjustable Arc Pad $280.00 *Accomodates several other manufacturers headrests. Call for details. E0955 Standard Adjustable Arc Pad $280.00 Page 4 of 7

Lifeform Ankle and Foot Positioning Stealth Hard Side Foot Stabilizers LifeForm Ankle Hugger Foot Stabilizers K0108 Small, Pair, Left and Right $166.00 K0108 Medium, Pair, Left and Right $166.00 K0108 Large, Pair, Left and Right $166.00 3610-5230L K0108 Left - Small $72.00 3610-5230R K0108 Right - Small $72.00 3610-5240L K0108 Left - Medium $72.00 3610-5240R K0108 Right - Medium $72.00 3610-5250L K0108 Left - Large $72.00 3610-5250R K0108 Right - Large $72.00 Lifeform Swing Away Lateral Support Hardware Choose your bracket and CURVED pad size Choose your bracket and PLANAR pad size Left 1.5" pediatric bracket lateral thoracic support package, Curved Pad Left 1.5" pediatric bracket lateral thoracic Right 1.5" pediatric bracket lateral Right 1.5" pediatric bracket lateral thoracic thoracic support package, Curved Pad Left 2" bracket lateral thoracic support package, Curved Pad Left 2" bracket lateral thoracic support package, Planar Pad Right 2" bracket lateral thoracic support package, Curved Pad Right 2" bracket lateral thoracic 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" Choose Swing-Away Hardware (required) Requires 3610-3110, 3120, 3210, 3220. Left 1.5" DoubleSwing pediatric swingaway Choose Swing-Away Hardware (required) Requires 3610-3110, 3120, 3210, 3220. Left 1.5" DoubleSwing pediatric swingaway Right 1.5" DoubleSwing pediatric swingaway Right 1.5" DoubleSwing pediatric swingaway Left 2" DoubleSwing Left 2" DoubleSwing Right 2" DoubleSwing Right 2" DoubleSwing LifeForm Swing-Away Width and Depth Extensions (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 Depth Ext. + 1", 2" Brkt., Left Depth Ext. + 1", 2" Brkt., Right Width Ext. + 1", 2" Brkt., Left Width Ext. + 1", 2" Brkt., Right Page 5 of 7

Choose your bracket and CURVED pad size Left 1.5" fixed pediatric bracket lateral thoracic support package, Curved Pad LifeForm Fixed Lateral Support Hardware Choose your bracket and PLANAR pad size Left 1.5" fixed pediatric bracket lateral thoracic Right 1.5" fixed pediatric bracket lateral thoracic support package, Curved Pad Right 1.5" fixed pediatric bracket lateral thoracic Left 2" fixed bracket lateral thoracic Left 2" fixed bracket lateral thoracic support package, Curved Pad Right 2" fixed bracket lateral thoracic Right 2" fixed bracket lateral thoracic support package, Curved 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" Accessories ROCK Sunshade $265.00 Underchair Cargo Tray (carries up to 10 lbs) Replacement Seat Cushion Covers E2610 E2610 E2610 Replacement Cover 8"-11" Seat Cushion Replacement Cover 11"-14" Seat Cushion Replacement Cover 14"-17" Seat Cushion $102.00 $102.00 $102.00 Additional Support Accessories Additional Support Accessories NOT tested with Transit. Must remove prior to tie down. K0105 IV Support Pole E1029 Battery/Vent. Accessory Tray $295.00 Requires 16" Rear Wheels and 8" casters. E2208 Oxygen Tank Holder (Does not include vent. mount for LTV) E1029 Ventilator Tray $370.00 for LTV Ventilator Series Only Requires 16" Rear Wheels and 8" Casters Custom Notes: Page 6 of 7

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