Please fill out all questions below.

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* 1. Child’s full name

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* 2. Child’s date of birth (MM/DD/YYYY)

Date / Time

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* 3. Child’s primary language

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* 4. Child’s health condition/diagnosis

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* 5. Parent or guardian name

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* 6. Parent or guardian email address

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* 7. Parent or guardian phone number

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* 8. Therapist name and credentials (if applicable)

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* 9. Therapy location (if applicable)

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* 10. How would an adapted toy car benefit the child?

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* 11. What are the family and/or therapist goals for child?

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* 12. Child’s height (inches)

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* 13. Child’s weight (lbs)

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* 14. Child’s hip to knee inseam length (inches)

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* 15. Child’s knee to foot inseam length (inches)

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* 16. Please list any known allergies

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* 17. Please list child’s medical equipment

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* 18. What is the child’s preferred method of mobility? (e.g., crawling, scooting, hopping, walking, wheelchair)

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* 19. Does the child wear orthotics/prosthetics? If yes, please provide details.

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* 20. Does the child attend a full time/part time school or day care program? If yes, please provide details.

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* 21. Does your child have seizures? If yes, please provide details.

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* 22. Does the child have a visual impairment?

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* 23. Does the child have a hearing impairment?

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* 24. Can the child hold his/her head up by himself/herself?

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* 25. Does the child sit independently for 5 minutes when placed

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* 26. Can the child use both hands to hold a toy?

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* 27. Does the child follow simple directions/commands?

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* 28. Is the child able to attend the car pick-up on the day of the build (10/12/2019)?

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* 29. Who will be attending the car build with your child to pick up the adapted toy car? (Please include name, relationship to child)

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* 30. Anything else you would like us to know about the child?


*Spots are limited. Finalists will be notified via phone or email for follow-up interview after review period.
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