Participant Medical Form

Vital Information, Medical History & Medical Release: Youth Challenge activities are designed to serve children and young adults (up to age 25) with physical disabilities. Individuals must have a physical disability (i.e. cerebral palsy; spina bifida; muscular dystrophy; amputee, orthopedic, visual or hearing impairment) and must be able to participate in age-appropriate activities. Youth Challenge currently does not serve children with a transmittable disease, or children who have a cognitive, behavioral, or emotional disability that prevents them from succeeding in Youth Challenge programs.

PARTICIPANT INFORMATION

First Name *
Last Name *
Date of Birth *
Street Address *
City *
Zip code *
Height *
Weight *
Gender *
MaleFemaleOther / Gender nonconforming
Participants Physical Disability *
Other disability
Equipment *
manual wheelchairpower wheelchaircrutcheswalkercaneothernone
other
Special Interests and Skills (i.e. hobbies, musical instruments, sports, drama, etc.)
We prefer that an adult is present during drop off. Can your participant be dropped off at home alone? *
(must be older than 12)YesNo

PARENT / GUARDIAN INFORMATION

Parent Name (#1) *
Parent Name (#1) Place of Employment *
Parent’s Name (#1) Cell Phone *
Parent Name (#1) Email *
*Parent Name (#2)
*Parent Name (#2) Place of Employment
*Parent’s Name (#2) Cell Phone
*Parent Name (#2) Email
*Address (If different than parent #1) *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

EMERGENCY CONTACT (other than primary guardian/contact)

Emergency Name *
Relationship *
Emergency Contact Phone *

Medical Insurance; Statement of Present Health:

Who is your medical insurance provider *(including Affordable Care Act, Medicare, Medicaid, or private insurance carrier)
What is the preferred hospital in case of an emergency?
Current Medications or Treatments:
Please list any medications (name, amount, and time administered) and treatments while your child is at Youth Challenge programs.
Therapist Name
Therapist Phone
Primary Care Physician
Primary Care Physician Phone
Allergies *
YesNo
Allergies Description (Food, insect bites/stings, etc.)
Epilepsy or seizures *
YesNo
Month and year of most recent seizure
Epilepsy/seizure medication, dosage, & instructions for staff
Epilepsy/seizure medication given after seizure lasts for how long?
Medical History *
Check all that apply. *AsthmaADD/ADHDAutism Spectrum DisorderDizziness or faintingBrittle bone(s)Unable to readTransmittable diseaseShortness of breathAbnormal blood pressureHeart trouble (murmur, palpitation, pounding heart)NervousnessIntellectual or developmental delayHead injuryBehavioral concernsEmotional or psychological concernsnoneother
If other Medical History please list
Has your child ever been seen by a psychologist/psychiatrist?
If yes, please describe why and when.
Youth Challenge serves young people with physical disabilities. If you checked boxes for behavioral concerns, ASD, or intellectual/developmental disability, please describe
Please describe any other medical conditions or concerns not listed above:

Personal Care Needs

Eating Habits: Check all that apply. *
needs to be fedneed help drinking (i.e. special cup, straw, etc.)difficulty swallowingspecial diet, food restrictionstube feedingNONEOther
Eating Habits other
Language and Communication: Please check all that apply. *
has difficulty being understood verballyuses communication board, iPad, or similar deviceuses sign language; ASL, otheruses eyes for yes and nocommunicates with cards, pictures, visual aidsReads BraileNO COMMUNICATION NEEDSother
Language and Communication Other
Participant needs to be lifted onto the toilet. *
YesNo
Participant has bowel control. *
YesNo
Participant has bladder control. *
YesNo
Participant needs toilet reminders *
YesNo
Participant wears diapers/pull-ups. *
YesNo
Participant has a tracheotomy *
YesNo
Participant uses a catheter *
YesNo
Participant has a feeding tube. *
YesNo

Emergency Instructions

In case of emergency, take the following action (select only one option): *
I hereby grant my consent to transfer my child to preferred hospital or the nearest clinic and call me or, in the event I am unable to be reached, the emergency contact listed on the front of this medical form. Follow the instructions of the attending physician.I do not give consent for emergency medical treatment of my child. In the event of illness or injury requiring medical treatment, TAKE NO ACTION and call me, or in the event I am unable to be reached, the emergency contact listed on the front of this medical form.

Medical Verification

By signing below, I certify that the information included herein is complete and accurate to the best of my knowledge *
A copy of your responses will be emailed to the address you provided.

Release of Liability

Release of Liability: The undersigned understands, recognizes, and assumes the inherent risks associated with Youth Challenge’s athletic and recreation programs, including the risks associated with transporting participants and volunteers to programs and related activities. In consideration for being permitted to participate as either a participant or volunteer in the recreational programming of Youth Challenge, the undersigned releases, waives, discharges and covenants not to sue Youth Challenge, its trustees, employees, agents, other volunteers, other participants, and if applicable, sponsoring agencies, advertisers, and owners or lessors of premises that host recreational programs from any and all liability arising out of any injury resulting from my child's participation.
In the event there is a need for emergency medical treatment for the minor participant or volunteer and the undersigned cannot be reached, the undersigned consents to and assumes the financial responsibility for such emergency treatment.
Lastly, the undersigned grants permission for the taking of pictures and videos and the release of general information about the minor participant or volunteers for use in media outlets or publications whatsoever, without there being any liability on the part of Youth Challenge, its employees, trustees, or agents.
I have read the above waiver and release, understand that I give up substantial rights by signing it and sign it voluntarily.
Name of parent or legal guardian *
Relationship to participant *
Electronic signature of parent or legal guardian *
Name of YC participant *
Please date this form. *

Verification

Please enter any two digits *Example: 12
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