SMS GoBabyGo Application 2024
We are excited to modify off-the-shelf, ride on cars for children in our local community that happen to have a mobility or developmental challenge.  

Application deadline TUESDAY, APRIL 23, 2024
This application will help us collect necessary information to determine how to plan, design and determine specific build options. 

On April 30th, you will be contacted, by Denise Boyles from Smyrna Middle School regarding your application status. 

Approximate date of workshop build will be between May 21 - 30 (specific date to be determined)

If you have questions/comments, please submit them at the bottom of this form.  
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Email *
Parent/Guardian's Name (first, last) *
Parent/Guardian's email address *
Parent/Guardian's phone number *
Person completing application -relationship to child *
Name of person completing application if not parent/guardian
Physical/Occupational Therapist's name (first, last)
Physical/Occupational Therapist's email address
Physical/Occupational Therapist's phone number
Permission for SMS GoBabyGo family coordinator (Denise Boyles) to contact your child's therapist
 *
Child's Name (first name only) *
Child's Date of Birth *
MM
/
DD
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YYYY
Medical Diagnosis/Nature of Child's Disability *
Tell us about the child's mobility or developmental challenges. *
At this time, how does your child move around his/her environment? *
What equipment does your child currently use? (i.e. every day equipment like a stroller or high chair, or specialized/therapeutic equipment like braces, walkers, standers, wheelchair, etc)
 *
Using diagram below, please take measurements (in inches) with your child seated in the most upright position they can comfortably maintain
Measurement B: Seat Depth (back of knee to bottom of child’s back)   
 *
Measurement C: Seat Height (top of knee to bottom of the heel
 *
Measurement F: Chair Height (top of shoulder to bottom)
 *
Measurement H: Head Height (top of head to bottom)
 *
Measurement K: Shoulder Width (shoulder WIDTH, measured along child’s back: edge of one shoulder to edge of other shoulder)
 *
Child's Weight (approximate) *
Does your child have experience with push buttons or switches?
 *
Can your child sit independently?
 *
Where do you plan to use the GoBabyGo car?  (check all that apply) *
Required
I will be able to take the GoBabyGo car home with me on day of Workshop (date to be determined in May)
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Tell us about your child's favorite toys, characters, color, music, etc.
 *
Use this space to tell us more details about your child and explain any further details from above answers. 

The more information you provide will help us better understand which car and modifications we need to prepare for a great fit.
 *
Additional comments/questions you have for the program coordinator
Submit
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