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 INFORMATIONFirst Name *Last Name *Date of Birth *Street Address *City *Zip code *Height *Weight *Gender *MaleFemaleOther / Gender nonconformingParticipants Physical Disability *Other disability Equipment *manual wheelchairpower wheelchaircrutcheswalkercaneothernoneother 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)YesNoPARENT / GUARDIAN INFORMATIONParent 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 CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEMERGENCY 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 *YesNoAllergies Description (Food, insect bites/stings, etc.)Epilepsy or seizures *YesNoMonth 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 concernsnoneotherIf 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 NeedsEating Habits: Check all that apply. *needs to be fedneed help drinking (i.e. special cup, straw, etc.)difficulty swallowingspecial diet, food restrictionstube feedingNONEOtherEating 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 NEEDSotherLanguage and Communication Other Participant needs to be lifted onto the toilet. *YesNoParticipant has bowel control. *YesNoParticipant has bladder control. *YesNoParticipant needs toilet reminders *YesNoParticipant wears diapers/pull-ups. *YesNoParticipant has a tracheotomy *YesNoParticipant uses a catheter *YesNoParticipant has a feeding tube. *YesNoEmergency InstructionsIn 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 VerificationBy electronically signing below, I certify that the information included herein is complete and accurate to the best of my knowledge *Please date this form. * VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
