Go Baby Go - Assisted Independence

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GoBabyGo of South Central Indiana is a program for children with motor and cognitive developmental delays.

The program works with Purdue engineering students in collaboration with physical therapists, recreational therapists, and engineers to use the donated vehicles from Cummins to supply design teams with the tools necessary for custom builds. Cummins currently provides students with the base-model vehicles, with engineers from Cummins and KPIT helping to facilitate customization for the vehicle recipients.

Students evaluate every child’s needs and work with their families to custom design a vehicle to meet specific physical therapy goals.

By receiving adapted battery-powered cars and four-wheelers, participants are able to gain mobility in their environment.

Go Baby Go Application

This application is for the children wanting to apply for a battery-operated, modified vehicle through Go Baby Go of South Central Indiana. This application can be completed by parents/guardians or therapists who would like to refer a child for a GBG vehicle.

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Go Baby Go of South Central Indiana Vehicle Application

Contact Information

Applicant Name(Required)

First Last

Parent/Guardian Name(Required)

First Last

Applicant Date of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

Address(Required)

Street Address City ZIP / Postal Code

Therapist Name

If the applicant is receiving physical, occupational, or recreational therapy, please complete the name, phone and email for their therapist. This is requested so GoBabyGo will be able to acquire information about specific mobility needs/challenges of the applicant.

First Last

Phone

Name of Clinic Applicant Attends

Application

Applicant's Diagnosis(Required)

Applicant's Height(Required)

Applicant's Weight(Required)

Can the applicant sit independently?(Required)

Yes

With Supports

Does the applicant lean to one side when sitting?(Required)

Yes

Can the applicant independently keep their head up when sitting?(Required)

Yes

With Supports

Does the applicant have difficulty reaching?(Required)

Yes

Does the applicant have difficulty using their hands and/or arms?(Required)

Hands Only

Arms Only

Difficulty with both

No Difficulty

Does the applicant have weakness on one side?(Required)

Yes

Does the applicant need any equipment?(Required)

Oxygen Tank

Braces

Ventilator

Other

Does the applicant use augmentative and alternative communication (AAC) or a speech generating device (SGD)?(Required)

Yes

Please provide details regarding the communication system being used:

Are there concerns for the applicants vision?(Required)

Yes

Please describe vision concerns:

How does the applicant move around their environment now?(Required)

What are your concerns about the applicant operating a ride-on vehicle?(Required)

What are the applicants favorite colors and/or characters?(Required)

Taking the Vehicle Home

Where will the applicant use the vehicle?(Required)

Home

School

Work

Other

Will you be able to take care of a GoBabyGo car by recharging the battery and storing it in a safe place when not in use?(Required)

Yes

Consent(Required)

By selecting "I agree", I give permission for GoBabyGo of South Central Indiana to contact the therapists and clinics listed above. This information will help GoBabyGo of South Central Indiana to customize the car for my child.

I agree.

Comments

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