MI Kids On The Move Child Application
Email address *
Terms of service:
An application does not guarantee your child will receive a car, each application will be reviewed to ensure the child qualifies for the program. If approved a representative will contact the family through email with further questions regarding the child and their needs. Applications for the next build are due by January 1st, if we still have openings and turn your application in after the cut off date we may still be able to add you to our spring build if we still have openings, if not you will be placed on the schedule for the next build. Please answer the questions below to the best of your ability. If you have any questions please message us on facebook at MI Kids On The Move or email us at mikotm@yahoo.com.
What equipment are you interested in for your child? Please check all that apply.
Child's Name *
Your answer
Birthday *
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DD
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YYYY
Age *
Gender *
Your answer
Parent's Name *
Your answer
Parent's Email *
Your answer
Phone Number (including area code)
Your answer
City/State *
Your answer
Is your child a patient at a hospital or a clinic? If so, which one? *
Your answer
Primary diagnosis that has led to limited mobility and how does it affect your childs daily living? *
Your answer
Secondary diagnosis
Your answer
List any known allergies that your child has (e.g. latex, cats, peanuts, etc.). Or put none if there is none. *
Your answer
List any braces, vest, equipment, etc. that your child wears. *
Your answer
Can your child sit independently? *
If not, where does your child need extra support?
Can your child stand? *
What toy or technology does your child currently use to move around? *
Your answer
By submitting the MI Kids On The Move application form, I certify that I have read agree to the terms of service above and I agree to be bound by the terms.
Parent's Signature (print first and last name) *
Your answer
Date *
MM
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DD
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YYYY
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