Modified Ride-on Car Application
Thank you for your interest in participating in our program. Please complete the following information to help us learn about your child. All selected participants will be notified by e-mail. If you have any questions, you can reach us at inspire@interactfirst.org.
Email address *
Parent(s) Name *
Your answer
Address, City, State and Zip
Your answer
Child's Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Height of Child *
Your answer
Weight of Child *
Your answer
Diagnoses of Child *
Your answer
Is your child involved in Physical and Occupational Therapy?
PT / OT Contact Information
Your answer
Where do you anticipate your child will use the car (check those that apply)
Tell us about your child: (Likes, dislikes, favorite colors, songs, activities)
Your answer
Does your child have any experience with switches and/or switch toys?
If Yes, what has your child used to activate a switch?
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