Chair Request

To request a chair, please send the following information in an email to

(You might find it convenient to copy/paste this page into an email)

Child’s Name

Parent’s Name


Phone Number
Child’s Weight (lbs.)

Child’s Height (in.)
Child’s Age



Zip Code


Medical Diagnosis Related to Mobility Challenges: (i.e. hemiplegia)

—YesNoDoes your child currently receive physical therapy for mobility related issues?
—YesNoIs your child able to sit unassisted?
—YesNoDoes your child have the ability to crawl?
—YesNoDoes your child currently use any other devices to assist with mobility?Medical Devices Used:
(i.e. Oxygen, Feeding, etc.)

Please tell us about how you came to discover Bella’s Bumbas.

—YesNoSmall basket for portable medical devices.
—YesNoKris Kart for portable ventalator.
—NoRightLeftR/L hand drive available for children unable to self-propel using both hands.
—YesNoChildren over 33 in. tall we offer an OPTIONAL 5 in. base extension for $15.00.
Which style chair from the picture below will work best? —1. Soft Bumbo2. Ingenuity3. High Back4. Kenzie