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Go Baby Go! Car Application

Today's Date

Child's Name

Child's Date of Birth

Medical Diagnosis

Name(s) of Parent/Guardian

Contact Email Address

Phone Number

Mailing Address

Height (in inches)

Inseam from hip to knee (inches)

Inseam from knee to foot (inches)

Weight

Please list your child's medical equipment.

Please list any known allergies.

Strengths

Challenges

Primary means of mobility for this child.

What goals/outcomes do you wish to see for your child?

Can your child sit unsupported for 10-15 minutes?

Yes
No

Can your child see?

Yes
No

Can your child hold his/her head up by himself/herself?

Yes
No

Can your child use two hands to hold a toy?

Yes
No

Therapist Name

Therapist Provider

Therapist Phone Number

Therapist Email Address

Pediatrician Name

Pediatrician's Practice Name

Pediatrician Phone Number

Who will be attending this workshop with your child? Please list name and contact information for each person attending.

Please upload a picture of the child.

Please upload a 30-second video of your child.

Are you willing to be contacted for research opportunities related to UCF Go Baby Go?

Yes
No

I’ve read the liability waiver and agree to the terms and conditions for use of the UCF Go Baby Go car. https://docs.google.com/file/d/1mJp5nWz5YkFYfJq4rU4ylErpKQI5X8_m/edit?usp=docslist_api&filetype=msword

Sign Here

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I’ve read and agree to the terms/conditions outlined in the media release linked below. https://docs.google.com/document/d/1jCGDbQS7G5OHiPxEgXKlz4aDkB3UutJlJOfC8UcP3cw/editJOfC8UcP3cw/edit

Sign Here

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