Survey Form   Do you currently use a powered lifting system to get your child into and out of the bathtub? Yes No Can your child sit upright on a powered lift without trunk or back support? Yes No Does your child need the capability of being lowered down into the water in a reclining position? Yes No If there is no government financial assistance available for a lifting device or your child does not qualify under the guidelines, would you be willing to pay out of pocket for the ability to safely lower and raise your child in a bathtub? Yes No How much would you be willing to pay out of pocket? Up to $1,000 $1,000 to $1,500 over $1,500   * Indicates field is required.