Be First to Experience Navigator Child Information Child’s Name: Age: Height: Weight: Medical Diagnosis (if applicable): Parent/Guardian Name: : Contact Number: Contact Email City: State Zip Code Mobility Status Child’s mobility level: Non-ambulatory Walks short distances with support Uses wheelchair full-time Daily Use & Environment Primary usage: Home School Outdoor/community All environments Typical surfaces: Indoor smooth floors Ramps Sidewalks Uneven ground Goals for EmpowerRide Navigator: Primary goal: Safe positioning Comfort for long sitting Ease of caregiver mobility School participat Current mobility device (if any): By submitting this form, you authorize EmpowerRide to collect the information provided, including health and mobility-related information, for the purpose of evaluating your mobility needs and connecting you with authorized Durable Medical Equipment (DME) providers, clinicians, therapists, ATPs, dealers, distributors, or other service providers involved in assessing, fitting, funding, or providing mobility equipment. Your information will only be shared with parties reasonably necessary to assist with your request. By submitting this form, you acknowledge and consent to such use and disclosure of your information. I have read and agree to the Privacy Notice and consent to the collection and sharing of my information as described above. Submit
