New Wheelchair Registration

Thank you for registering your CLASP wheelchair. CLASP is committed to quality and has developed a system for tracking and responding to product quality issues.

Wheelchair registration through this online form is required to activate the warranty and to enable CLASP to address product quality issues. All client information will be kept confidential. Information on wheelchairs collected through this form will be shared with suppliers/manufacturers, USAID, and other relevant stakeholders at Momentum Wheels for Humanity's discretion.

Fields with an asterisk (*) are required.
Date wheelchair provided:*
MM slash DD slash YYYY
Wheelchair model:*
Wheelchair serial number:*
Wheelchair service provider organization:*
City and country where wheelchair was provided:*
City Country
Client’s name or ID number:*
Is the client interested in receiving a questionnaire regarding their wheelchair? (optional)
- Yes
- No
If yes, please select the client’s preferred method for receiving the survey:
- Facebook (enter client's user name)
- WhatsApp (enter client's number, including country code)
- Email
- Other
Facebook
WhatsApp
Email
Other