Participant Intake Form - Youth Challenge

PARTICIPANT INTAKE FORM

Please note the following:

Youth Challenge activities are designed to serve young people (ages 4-19) with physical disabilities. Individuals must have a physical disability (i.e. cerebral palsy; spina bifida; muscular dystrophy; orthopedic, visual, or hearing impairment) and are able to participate in age-appropriate activities.

**Please complete the ENTIRE form and click “submit” at the end. For questions, contact:
Mackenzie Vecchio, Director of Program Services, at [email protected] or (440) 892-1001 x 18.

PARTICIPANT INFORMATION

Participant last name: *

Participant first name: *

Participant date of birth: *

Participant age: *

Street address: *

City: *

Zip code: *

Primary contact name: *

Primary contact email: *

Primary contact phone number: *

Can receive text messages: *

Yes

Participant's physical disability: *

Participant interests and hobbies *

School Name

Emergency contact name, other than primary contact listed above: *

Emergency contact phone number: *

Today's Date