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

Prefer not to answer

Participants Physical Disability *

Other disability

other

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)

DEMOGRAPHICS

Please Note

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.

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

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. *