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
Address, City, State and Zip
Date of Birth
Height of Child
Weight of Child
Diagnoses of Child
Is your child involved in Physical and Occupational Therapy?
PT / OT Contact Information
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)
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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