If you haven't registered with the LifeNets Wheelchair Project, please fill out the contact information below. If you have previously registered on the site, please Log-In to request a wheelchair
The following fields are required:
Please supply your full name (only your first name will be displayed to the public.)
Please supply your city, state, and zip
Please supply a username and password to log-in to the site in the future.
Please supply a phone number or email address
Only your first name and selected contacted information will be viewable to the public