2024 GoBabyGo New Trier Registration

GoBabyGo Registration - 2024 New Trier High School & Illinois Spina Bifida Association

This program is for children with disabilities age 1-3 who have significant mobility deficits. Cars will be delivered on Thursday, February 29 in Winnetka, IL. Cars are free.
Parent Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Child's Name*

First NameLast Name
Child's Gender
Child's Date of Birth*

MonthDayYear
Date
Child's condition causing limited mobility*
Child's Weight (pounds)*
Child's Height (inches)*
Does your child have a cognitive age of at least 12 months?*

YesNo
Does your child have a severe visual disorder?*

YesNo
Does the child have enthusiastic parents able to supervise use of the car?*

YesNo
Does your child have head and trunk control?*

YesNo
Can your child sit upright without support?*

YesNo
If your child cannot sit upright without support, do you have a seat support system that you want to use with the GoBabyGo car?

YesNo
If yes, please tell us the dimensions (length, height, width) or name of the system.
Which of the following would be most appropriate for your child?

5-point harness (shoulder straps & seat belt)Seat belt across waist
Does your child lean to one side, fall forward, or arch back (trunk extension)?
Is your child able to hold her/his head up?*

YesNo
If your child is not able to hold his/her head up, do you have a HeadPod Head Support System or a similar device?
Can your child reach a steering wheel and turn it?*

YesNoOther
Does your child require a breathing apparatus or a feeding tube holder added to the car?
Please describe what, if any, major mobility deficits your child has in the upper and/or lower limbs.*
Is there any other information that will help us enable your child to drive the car?
Please mark your 1st preference for car fitting sessions. Car fittings will be held at the New Trier High School Winnetka campus (385 Winnetka Ave, Winnetka, IL)*
Please mark your 2nd preference for car fitting sessions.
Please mark your 3rd preference for car fitting sessions.
Should be Empty:

GoBabyGo Registration - 2024 New Trier High School & Illinois Spina Bifida Association