Parent/Caregiver Information

Go Baby Go (GBG) is a community-based outreach program that works with families, clinicians and industry to provide pediatric equipment to children with disabilities for movement, mobility and socialization. The primary mission of GBG is to provide modified ride-on cars to children with disabilities to use as a powered mobility device for fun, function, and exploration. Many children with disabilities are unable to be independently mobile, or require expensive, awkward, and potentially socially stigmatizing equipment in order to move and play with family and friends. Left stationary or heavily reliant on others for mobility, these children have reduced opportunities for social interaction and engagement. Thirty years of research has consistently demonstrated the cognitive, motor, language, and social benefits to children with motor disabilities when provided access to a powered mobility device during early childhood (6 months to three years old). With no commercially available device, such as motorized wheelchairs, for this population, the vehicles need to be built. Go Baby Go provides modified ride-on cars to fulfill this gap in technology.

Parent/Caregiver Information

Parent/Caregiver Name ______

Child’s Name ______

Address ______

Phone ______Email ______

Child’s Information

Date of Birth ______Age ______

Height (Inches) ______Weight (lbs) ______

Diagnosis(es) ______

Describe Level of Functioning (i.e. can the child support itself in sitting?)
______

Current Therapist (Please provide their email or phone number so that we may contact them)

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Known Postural Supports Needed: ______

______

______
______

Head switch? YES NO

Harness? YES NO

Lateral supports? YES NO

Supportive seating? YES NO If yes, please explain below: ______
______
______

If appropriate please provide the degree of tilt that is most functional for the child ______

☐ If possible, please provide a picture of the child in their current seating system or in a trial Go Baby Go Car, so that way we can ensure to have the proper supports in place in their car.

If the child requires a complex seating system please provide us with the following measurements:

A-Shoulder Width______

B- Chest Width ______

C- Hip Width______

D-Width at Knee______

E- Seat to Top of Head ______

F-Seat to Top of Shoulder (L, R) ______

G- Seat to Armpit (L, R) ______

H-Chest Depth (L, R) ______

I-Seat Depth (L, R) ______

J-Seat to Footplate (L, R) ______

Disclosure: Go Baby Go Oregon reserves the right to accept or decline any applicant. Go Baby Go Oregon will not discriminate based race, creed, color, religion, sex or national origin. Go Baby Go Oregon will decide on which applicant will receive financial assistance.

Release of Liability

In consideration of the receipt of certain equipment or services awarded by Go Baby Go Oregon (the Recipient thereof), him/herself or through his/her parent or legal guardian, hereby releases and forever discharges Go Baby Go Oregon, their members, employees and officers from and against any and all claims, of any type, which arise from or relate to:

1) Any alleged malfunction of or defect in the enabling equipment;

2) Any allegation that the enabling equipment was not appropriate or suitable for the recipient;

3) Any other matter related to the recipient’s receipt or use of the enabling equipment or service.

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Parent/Legal Guardian Signature Date

Disclaimer

The equipment we provide carries no warranty from Go Baby Go Oregon, even in the event of malfunction resulting in injury, gives rise to no liabilities on the part of Go Baby Go Oregon. Go Baby Go Oregon is in no way responsible for reclaiming, disposing of, maintaining or repairing equipment. It is the sole responsibility of the Recipient’s legal guardian(s) to maintain and repair the equipment.

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Parent/Legal Guardian Signature Date