Application Forms

Downloads

Parents Application Form - Download

Therapists Application Form - Download

Parents Form

Thank you for your interest in GoBabyGo. We are delighted to see if we can provide a car for your child. Can you please complete the enclosed form and also ask your therapist to complete the identified aspects of the form and return it to us.

The process from here is once we receive your information, we will send this to a screening group which will approve or decline your application. We will let you know as soon as we hear from them, and link you into our next handover.

Please complete this form as part of the application process for GoBabyGo!

The details of the Child

Name: *

DOB: *

Medical Condition: *

Picture of child sitting (from side) *

Picture of child sitting (from front) *

Does your child use a Shuttle Discovery wheelchair seat? *

YES

The details of Parents

Names: *

Addresses: *

Email: *

Phone:

The name of Therapist

Name: *

Email:

Organisation:

Phone: *

Paediatricians details:

Media permission

I give Go Baby Go New Zealand Pacific permission to use any photographs or video footage taken of myself, my child or any donation days for promotional purposes (ie media, facebook, our website)

Therapists FORM

The details of Child

Name: *

Names of Parents *

DOB: *

Medical Condition: *

Physical ability: *

Has some walking ability but this is not functional or effective due to difficulties with balance, strength, coordination, endurance or other impairment

Not yet walking due to delayed milestones but expected to walk independently in the future e.g. Cerebral palsy (GMFCS I-II), hypotonia , ill health impacting on gross motor development, global delay

Not yet walking but expected to have some assisted walking ability in the future e.g. cerebral palsy (GMFCS III), low level spina bifida, SMA type III etc.

Expected to have none or very limited walking ability e.g. cerebral palsy (GMFCS IV-V), SMA II, arthrogryposis, SCI, higher level spina bifida etc.

Dynamic Sitting *

With significant support

With moderate support

With minimal support

Independently

Standing *

With significant support

With moderate support

With minimal support

Independently

Postural support needed in sitting *

Sits independently without needing support (Chailey level 6-7)

Sits fairly well but needs support for safety (Chailey level 4-5)

Head control is fair to good but unable to sit without support (Chailey level 2-3)

Needs head and body supported in sitting position (Chailey level 1)

Head control *

Needs full support

Needs some supports

Intermittent

Will need support when driving

Well established

Hand Function for driving: *

Adapted steering wheel

Standard steering wheel

Buddy Buttons

Head Switch

Highest level of floor Mobility *

Rolling

Scooting

Crawling

Supported Walking

Independent Walking

Cognitive ability *

Limited ability to understand and interact with external environments

Limited ability to understand and follow instructions

Easily understands and can follow instructions. Interested in other people and the external environment.

Power ability *

Already has powered mobility device and uses it most of the time

Is in the process of getting a power mobility device or still learning to use one

Is not expected to get a powered mobility device in the next year or more.

Will Postural Support be required for safety during driving: *

Yes

Therapist’s availability for involvement

Initial Fitting Ongoing follow up

GBG Therapist Conversation

Preferred contact:

Phone

Best day/time to phone:

Diagnosis: Please list all health and disability diagnoses here *

List any orthotics used

Current functional goals / Goals you would like to address with GoBabyGo

Mobility equipment history / experience

Current weight:

Measurements Required

Overall height *

A - Shoulder Width (cm) *

B - Hip Width (cm) *

C - Seat to Top of Head (cm) *

D - Seat to Shoulder (cm) *

E - Seat to Inside of Knee (cm) *

F - Back of Knee to Back of Heel (cm) *

Any queries, please contact dana@kiwikidscharity.org.nz