Help us get to know your kid!
Young Life Capernaum wants all experiences to be safe and healthy for every participant. Thank
you for taking the time to complete this form so that we may know how to best serve your son or daughter at Capernaum! This information will go to our Capernaum Director, Erin, and shared with trained Volunteer Leaders.
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name *
Your Email *
Your Phone number *
CHILD'S INFORMATION
Child's Name *
Child's Date of Birth *
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DD
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Community you live in/School District *
Describe your child's Disability  *
Dietary Restrictions or Allergies?
Medical history or pertinent medical things we should know.
Any medications they might need with dosage
Are there any noises, activities or situations that bother your child?
Is your child prone to elope?
If/When your child is overwhelmed, what are some ways that we can support them?
Are there any physical activities or games that your child should not participate in?
Ways that leaders can serve your child during club (i.e. during meals, mobility assistance, bathroom assistance etc.)
Some of your child's favorite things
Any other things you think we should know to best support your child!
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