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.
  • PARTICIPANT INFORMATION

  • PARENT / GUARDIAN INFORMATION


  • EMERGENCY CONTACT (other than primary guardian/contact)

  • Medical Insurance; Statement of Present Health:

  • Personal Care Needs

  • Emergency Instructions

  • Medical Verification

  • A copy of your responses will be emailed to the address you provided.
  • 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.

 

Verification