Request a GO Kart

Interested in receiving a GO Kart from one of our donors? Complete the form below to add your hospital to our wish list!

Your Name*
Your Email*
Hospital Name*
Hospital Shipping Address*
Street Address Address Line 2 City State ZIP Code
How many GO Karts are you interested in receiving for the hospital?*
What is your role at the hospital?*
How many inpatients were admitted to your hospital in the last year?*
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