GoBabyGo Registration - April 20, 2024 event in Lombard, IL
This program provides free, custom electric cars to children with disabilities age 1-3 who have significant mobility deficits. There are two fitting sessions, one at 11am, the other at 1pm. Each session should take approximately 1-2 hours. This event is a collaboration between the Kiwanis Club of River Forest - Oak Park, NuMotion, and the Illinois Spina Bifida Association.
Parent Name
*
First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Child's Name
*
First Name
Last Name
Child's Gender
Please Select
Female
Male
Prefer not to say
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's condition causing limited mobility
*
Child's Weight (pounds)
*
Child's Height (inches)
*
Does your child have a cognitive age of at least 12 months?
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Yes
No
Does your child have a severe visual disorder?
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Yes
No
Does the child have enthusiastic parents able to supervise use of the car?
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Yes
No
Does your child have head and trunk control?
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Yes
No
Can your child sit upright without support?
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Yes
No
If your child cannot sit upright without support, do you have a seat support system that you want to use with the GoBabyGo car?
Yes
No
If yes, please tell us the dimensions (length, height, width) or name of the system.
Which of the following would be most appropriate for your child?
5-point harness (shoulder straps & seat belt)
Seat belt across waist
Does your child lean to one side, fall forward, or arch back (trunk extension)?
Is your child able to hold her/his head up?
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Yes
No
If your child is not able to hold his/her head up, do you have a HeadPod Head Support System or a similar device?
Can your child reach a steering wheel and turn it?
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Yes
No
Other
Does your child require a breathing apparatus or a feeding tube holder added to the car?
Please describe what, if any, major mobility deficits your child has in the upper and/or lower limbs.
*
Is there any other information that will help us enable your child to drive the car?
Submit
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