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Youth Participant Sign Up
Sign Up Form for Child with Health or Physical Challenges
* Indicates required question
Email
*
Your email
Child's Name
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Your answer
Child's Date of Birth
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MM
/
DD
/
YYYY
Guardian's Name
*
Your answer
Guardian's Phone Number
*
Your answer
Location
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Your answer
Tell us about the applicant and the health challenges they are experiencing?
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Your answer
Are the physical health challenges…
*
Choose
Temporary
Permanent but not life threatening
Permanent and life threatening
Does the applicant currently use any of these devices?
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Scooter
Manual Wheelchair
Power Wheelchair
Other:
Tell us more about the child and their ideal Outdoor Dream
*
Your answer
Does the applicant have any other hardships in life in addition to their health challenges?
*
Your answer
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