WELCOME
WHO WE ARE
What is PLAAY on the Move?
WHAT WE DO
HOW TO SUPPORT
Donate
WELCOME
WHO WE ARE
What is PLAAY on the Move?
WHAT WE DO
HOW TO SUPPORT
Donate
Car Build Intake Form
Please submit the following information to request your spot for the next GoBabyGo Car Build
Child First Name
*
First Name
Last Name
Parent/Caregiver Contact Name
*
First Name
Last Name
Parent/Caregiver Email
*
Referring Therapist Name
*
First Name
Last Name
Referring Therapist Email
*
Age of Child
*
Height of Child
*
In inches
Weight of Child
*
In pounds
Has the child successfully trialled a GoBabyGo car that accommodates the child's unique needs (and also fits the child appropriately?)
*
Yes*
No
If answered yes above, please specify which one
Lightening McQueen
Frozen
BMW
Jeep
Other
Please use the diagram to complete the measurements in the following questions
A - Shoulder Width
*
in inches
B - Chest Width
*
in inches
C - Hip Width
*
in inches
D - Width at Knee
*
in inches
E - Seat to Top of Head
*
in inches
F - Seat to Top of Shoulder (L,R)
*
in inches
G - Seat to Axilla (L,R) (armpit)
*
in inches
H - Chest Depth (L,R) Back to Top of Chest
*
in inches
I - Seat Depth (L,R) Actual - 2-3 Fingers
*
in inches
J - Seat to Footplate (L,R)
*
in inches
E + J - Head to Floor (with hips and knees at 90 degrees)
*
in inches
F + J - Shoulder to Floor (with hips and knees at 90 degrees)
*
in inches
Other Measurements that may impact position in a modified ride-on car
Please comment on child's ability to demonstrate following tasks and provide necessary information such as level of assist
Sitting Balance (e.g. level of independence maintaining this position, specifics in regards to alignment)
*
Standing Balance (e.g. level of independence maintaining this position, specifics in regards to alignment)
*
Forward Righting Reactions (e.g. present, absent, emerging)
*
Lateral Righting Reactions (e.g. present, absent, emerging)
*
Posterior Righting Reactions (e.g. present, absent, emerging)
*
Supine (back) to prone (belly) transitions (e.g. level of independence, quality of movement)
*
Prone (belly) to supine (back) transitions (e.g. level of independence, quality of movement)
*
Prone (belly) to quadruped (hands and knees) transitions (e.g. level of independence, quality of movement)
*
Sit to stand transitions (e.g. level of independence, quality of movement)
*
Other functional skills/capabilities of the child that may impact position in/use of a modified ride-on car
Please provide additional comments about the child that you believe will be helpful (e.g. social or family considerations)
Thank you!
