Go Baby Go Contact Form: - Variety Alberta

Parent and/or Caregiver Name *

First

Last

Name of Child *

Age of Child *

Type of Disability *

Please explain the nature of the disability and needs of your child so we can determine the modification needs/adaptation requirements for the Go Baby Go vehicle.

With our current situation with COVID 19 we will be gifting our Go Baby Go cars differently than we typically do. Using strict social distancing protocol and where everyone present at the gifting MUST wear a mask: *

Are you open to receiving your vehicle over the next few months in this manner?
Would you prefer to wait until the fall or later to receive your vehicle?

We currently gift our GBG cars in Alberta and Saskatchewan. In order to keep our costs low, we do our gifting in larger municipalities. Please choose the city that you would be able to pick your car up from: *

Calgary
Edmonton
Regina
Saskatoon

Contact Phone Number *

Contact Email *

Contact Address

Name of Physiotherapist and/or Occupational Therapist

PT and/or OT contact information

*NOTE:

Variety Alberta has the right to determine the best fit of vehicle for your child(ren).

Please note, there may be situations and circumstances where a family may request a vehicle for their child and not be able to receive one. We will do our best to accommodate all requests.

Depending on the information that we receive regarding your child’s need, Variety Alberta may need to follow up with you to get additional information to determine your child’s eligibility for the program.

If you are eligible for a Go Baby Go car you will be required to:

Sign a release of liability form before receiving the equipment.
Provide an image and story telling why a Go Baby Go car would be important for your child that we can use and share with our donors; and
Sign a consent form allowing Variety Alberta to use images and/or video collected from the Go Baby Go car giveaway event.

Thank you!