Participant Medical Form

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.

(must be older than 12)

This section is not required and information provided will not be shared. Information will not impact the participant’s eligibility for programming. YC receives substantial funding from Foundations and Community Partners. Often, they require certain demographic and income data to ensure that their grantees meet requirement set forth in specific funding guidelines. If you are comfortable doing so, please complete the following section.

(including Affordable Care Act, Medicare, Medicaid, or private insurance carrier)
Please list any medications (name, amount, and time administered) and treatments while your child is at Youth Challenge programs.
(Food, insect bites/stings, etc.)
Check all that apply. *
If yes, please describe why and when.