Go Baby Go! Application
Do you know a child who would love a Go Baby Go car?

Down Syndrome Foundation of Florida, Orlando Health and UCF Go Baby Go! are partnering to provide several Go Baby Go! cars to our members.  The best part is that these cars will be assemble by our members age 10-15 who are participating in our iCan Excel class.  What a great way to give back to the community!  If your son/daughter meets the following requirements we hope you will consider applying:

    - Is between the ages of 6 months and 5 years old
    - Can sit supported for 10 to 15 minutes
    - Can see
    - Can hold his/her head up by himself/herself
    - Can use two hands to hold a toy
    - Parent/Guardian is able transport the built car home following the event

Space is limited, so apply today!
Sign in to Google to save your progress. Learn more
Applicant Information
Child's First Name: *
Child's Last Name: *
Address 1: *
Address 2:
City: *
State: *
Phone Number: *
(XXX)XXX-XXXX
Date of Birth: *
MM/DD/YYYY
Diagnosis *
Height (in inches): *
Weight (in pounds): *
Please list your child's medical equipment: *
Please list any known allergies. *
Strengths: *
Challenges: *
Therapist Information
Therapists Name: *
Therapy Provider: *
Therapist Phone Number: *
(XXX)XXX-XXXX
Email Address: *
Physician Information
Pediatrician Name: *
Practice Name: *
Pediatrician Number: *
(XXX)XXX-XXXX
Parent/Guardian Input
Name(s) of Parent or Guardian: *
Email (Please provide the email address for the person we should contact regarding this application): *
What goals or outcomes do you wish to see for your child? *
Who will be attending the workshop with your child? (Please include name, relationship to child, and age for each person attending.): *
Can your child sit unsupported for 10-15 minutes? *
Can your child see? *
Can your child hold his/her head up by himself/herself? *
 Can your child use two hands to hold a toy? *
Who will be attending the workshop with your child? (Please include name, relationship to child, and age for each person attending.) *
Photo, Video and Research Release Form
Down Syndrome FOUNDATION of Florida, Orlando Health and  University of Central Florida gather photos and video of people with Down syndrome, their families and friends for the purposes of education, celebration, promotion and awareness.  The FOUNDATION and our Go Baby Go! partners also use such media as content in presentations that teach families and educators across the nation how to work with children with Down syndrome.

Please read and sign the following release if you are willing to grant us
permission to use photos or videos involving you, your child or family and
or your loved one to be involved in our research.  

I hereby grant The FOUNDATION, Orlando Health and UCF, their affiliates, representatives and employees, the right to take and use photographs or video of me and/or my minor child in connection with the above-identified purposes.  
Comments:
*
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Down Syndrome Foundation Of Florida. Report Abuse
Google Forms