Participant Medical Form - Youth Challenge

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.

First Name *

Last Name *

Date of Birth *

Street Address *

City *

Zip code *

Height *

Weight *

Gender *

Male

Female

Other / Gender nonconforming

Participants Physical Disability *

Other disability *

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? *

Yes

(must be older than 12)

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) *

Apt, suite, etc.

Country

City

State

Zip code

Emergency Name *

Relationship *

Emergency Contact Phone *

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 *

Yes

Allergies Description *

(Food, insect bites/stings, etc.)

Epilepsy or seizures *

Yes

Month and year of most recent seizure *

Epilepsy/seizure medication, dosage, & instructions for staff *

Epilepsy/seizure medication given after seizure lasts for how long? *

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: *

Eating Habits other *

Language and Communication: Please check all that apply. *

has difficulty being understood verbally

uses communication board, iPad, or similar device

uses sign language; ASL, other

uses eyes for yes and no

communicates with cards, pictures, visual aids

Reads Braile

NO COMMUNICATION NEEDS

other

Language and Communication Other *

Participant needs to be lifted onto the toilet. *

Yes

Participant has bowel control. *

Yes

Participant has bladder control. *

Yes

Participant needs toilet reminders *

Yes

Participant wears diapers/pull-ups. *

Yes

Participant has a tracheotomy *

Yes

Participant uses a catheter *

Yes

Participant has a feeding tube. *

Yes

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.

By electronically signing below, I certify that the information included herein is complete and accurate to the best of my knowledge *

Please date this form. *