Request for a Modified Car
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1. Parent/ Caregiver's Name
First Name: *
Last Name:  *
2. Email Address:  *
3. Phone Number: *
4. Address
Applicants must reside in Oregon or Southern Washington. We cannot ship modified equipment. 
Address Line 1: *
Address Line 2:
Postal Code:
City: *
5. Child's Name
First Name: *
Last Name: *
6. Child's Date of Birth
MM
/
DD
/
YYYY
7. Child's Age
ex: 18 months
8. Child's Height
ex: 30 inches
9. Child's Weight
ex: 32 lbs
10. Child's Diagnosis
11. Child's Current Mobility Level
Please describe your child's current mobility level.
12. Child's Therapist Information *
Please provide your current therapist's name and contact information (preferably email). 
13. Switch Positioning
Please select a switch positioning that would support your child's needs.
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14. Postural Trunk Support Needs
Please select the postural trunk support that best supports your child's need.
Clear selection
14a. Custom Postural Trunk Seat
If you have selected custom seat adaptation in question 14, please use this section to specify your child's custom postural needs. Otherwise, please skip this question.
15. Ride-On Car Preference
Please work with your therapist to help choose the most appropriate car for your child. If you are still unsure, a Go Baby Go Committee Member can assist with finalizing the right car for your child. 

Please select your child's car based on the car specification sheet. 
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Donation
Go Baby Go Oregon is funded partly through the Doernbecher Foundation and other sponsors. However, we do not receive any recurring support and operate completely on donations or reimbursements from families. $200 covers the cost of one car plus modification supplies. Our clinicians and volunteers donate their time and effort to modify cars to help keep costs to a minimum. If you are able to contribute a donation to Go Baby Go Oregon, please follow the link http://support.ohsufoundation.org/DCHV16CG and indicate below your contributing amount. If you cannot contribute at this time, please indicate below N/A. We will review applications on a case-by-case basis to determine if Go Baby Go Oregon can cover the costs of adaptation needs.
Agreement *

Should the application be accepted, you will be notified of an approximate timeline of when the modified car will be finish.

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.

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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