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): Submit
