AdaptoPlay

2023 Go Baby Go Referral Form

Please fill out with the CHILDS contact information

* First Name

* Last Name

* Email

* City

* State

* Postal Code

* Phone

* Birthday

* Gender

Please check "Child" below

* Contact type

PLEASE DOWNLOAD AND UPLOAD IMAGE RELEASE HERE. ALSO CHECK "YES" to the image/event release question

* Document

After clicking the upload button be sure to select the drop down menu when searching and select "All Files" to see all file types on your PC. This way PDFs and Word Docs will show up.

* Image/event release

PLEASE UPLOAD "GO BABY GO REFERRAL FORM" below

* Other

* Occupation/Therapist/Referral

Therapist Referring

* Name of therapist, email and phone number

Go Baby Go Referral Form

Please download all forms in the "Downloads" section below, fill out completely, and upload. The referring therapist must complete the GBG Referral Form. The families must sign the IMAGE and EVENT RELEASE and the RELEASE AND WAIVER OF LIABILITY. All documents must be completed and uploaded to complete. You may either do this digitally on phone or PC - OR - Print, scan, and upload.

To sign the forms digitally - please download Adobe Acrobat Reader on your phone or PC.

PLEASE NOTE: DUE TO COVID WE ARE CURRENTLY ONLY ACCEPTING APPLICATIONS FOR THE WAITING LIST FOR 2021.

AdaptoPlay

2023 Go Baby Go Referral Form

Please fill out with the CHILDS contact information

Please check "Child" below

PLEASE UPLOAD "GO BABY GO REFERRAL FORM" below

Go Baby Go Referral Form

Downloads

GBG Referral Form

Release and Waiver of Liability Form

Image and Event Release Form