Programas

1. Nombre del padre/madre/cuidador(a) *

First Name

Last Name

3. Teléfono *

(###)

###

####

4. Dirección *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

5. Nombres de niño(a) *

First Name

Last Name

13. Switch Positioning

Please select a switch positioning that would support your child's needs.

Midline Hand Switch

Right Side Hand Switch

Left Side Hand Switch

Right Side Head Switch

Left Side Head Switch

14. Postural Trunk Support Needs

Please select the postural trunk support that best supports your child's need

Seatbelt: Child can sit independently without trunk support

4-Point Harness: Child can sit with minimal trunk support

5-Point Harness: Child requires significant trunk support

Custom Seat Adaptation: Child may require additional postural needs

Ride-On Car Preference

Please select your child's car based on the car specification sheet.

Paw Patrol

Little Lightning McQueen

Doc McStuffins

Frozen

Convertible

Large Lightning McQueen

Large Frozen

Mickey Mouse Roadster

Nombre del padre/cuidador *

First Name

Last Name

Teléfono *

(###)

###

####

Dirección *

Dirección, Ciudad, estado/provincia, código postal, País

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Nombre del niño *

Nombre, Apellido

First Name

Last Name

¿Tiene un interruptor?

No se incluye uno con el juguete; podemos ofrecer recursos para obtener uno si es necesario.

Sí

No

¿Dónde has oído hablar de nosotros?

Marque todo lo que corresponda

Terapeuta

Miembro de la familia o amigo

Otra organización comunitaria

Evento/taller anterior de Go Baby Go

Medios de comunicación social

Parent/Guardian's Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name *

First Name

Last Name

Does your child have a vision impairment?

Yes

No

Do they have any of the following diagnoses:

Blindness

Cortical Visual Impairment

Optic Nerve Hypoplasia

Septo-optic dysplasia

Other

Are there any supports that would help your child pay attention to pictures in the book?

Please check all that apply

Added texture to pictures (touch and feel book) – fabric or other materials

Books with recorded sounds (such as animal noises in goodnight gorilla)

High contrast pictures – black background with a bright colorful picture in center of the page

Flashlight to highlight pictures on the page (typical used for children with early stages of cortical visual impairment)

Borders around picture and or page

Manipulable objects that go with the book

A topic that they are really into and/or is their preferred interest

Does your child have difficulty turning pages of any of the following book types?

Please check all that apply

Board Book - Yes

Board Book - No

Paper Book - Yes

Paper Book - No

Are there any supports that would help your child participate in turning the pages of a book:

Increase spacing between pages by using small or large pom poms or raised sticker dots

Using tabs created via popsicle sticks to lift the page open

Are there any language goals that you're working on right now that would be great to target in a book:

Please check all that apply

Directing actions: words like "go", "stop"

Early Prepositions: words like "in", "out", "under"

Colors

Animals

Emotion words: "happy", "sad", "afraid"

Body parts

Numbers

Alphabet

Other