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2023 -2024 Capernaum Participant Information Form
Please fill out this form for your student to participate in Young Life Capernaum Clubs for this school year.
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Email
*
Your email
Participant's Last Name
Your answer
Participant's First Name
Your answer
Gender
Female
Male
Other
Clear selection
Parents Name(s)
Address
Your answer
City
Your answer
Zip
Your answer
Parent or Guardian Email
Your answer
Whose Email
Your answer
Secondary Email
Your answer
Whose Email
Your answer
Parent or Guardian Phone Number
Your answer
Whose Phone Number
Your answer
Secondary Phone Number
Your answer
Whose Phone Number
Your answer
Student Date of Birth
Your answer
School/Year Graduated or Will Graduate
Your answer
What activities does the participant enjoy?
Your answer
What extracurricular activities is participant involved in and when do they meet? (i.e. Special Olympics Basketball-meets Tues, 6pm at YMCA)
Your answer
Describe participant's disability:
Your answer
Is the participant's speech understandable?
Yes
No
Other:
Clear selection
Can participant feed him/herself?
Yes
No
Other:
Clear selection
Any food restrictions?
Your answer
Allergies and Restrictions (food, drug, insect, plant, other)
None
Peanut
Tree nut
Egg
Fish
Milk
Dairy Intolerance
Gluten Intolerance
Shell Fish
Soy
Celiac disease
No pork
Vegeterian
Vegan
Other:
Is your child on medication? If yes, please list.
Your answer
Have medications changed recently?
Yes
No
Clear selection
Can the participant swim independently?
Your answer
What type, if any, noises, activities or situations bother the participant?
Your answer
Are there any physical activities or games that the participant should not participate in?
Your answer
Is the participant aggressive? If yes, how do you control his/her behavior?
Your answer
How does participant deal with people he/she does not know?
Your answer
If female and menstrual cycle begins at YL, how does she take care of herself?
Your answer
Check all that apply:
Glasses
Contact lenses
Helmet
Uses sign language
Uses a language board
Has a shunt
Is allergic to latex
Uses a wheelchair
Uses a walker
Uses a hearing aid
Has a rod supporting bones
Uses toilet independently
Uses toilet w/ supervision
Wears adult briefs
Uses signs to indicate to need for toileting
Bowel/Bladder Training
Assistance with bathrooming
Lifting/positioning
Clean intermittent catherterization
External catherter
Ostomy care
Respiratory percussion
Respiratory postural
Respiratory drainage
Respiratory suctioning
Collect and/or test blood/glucose/insulin pump
Other:
Chronic, recurring, and special health conditions
Athritis
Diabetes
Kidney disease
Heart disease
Asthma
Bleeding/Clotting disorder
Hearing Impairement
Head or spinal injury
Dental challenges
Behavioral challenges
Developmental challenges
Convulsions in last 60 days
Sickle Cell Disease (not trait)
ADHD
Enuresis (involuntary urine discharge)
Cystic Fibrosis
Epilepsy/Seizures
Other:
Does participant have an inhaler, epi-pen, and/or other emergency medication at all times.
Your answer
Any other medical explanations or health care needs?
Your answer
Is there anything else you would like us to know to help us care for the participant?
Your answer
Any hygiene instructions?
Your answer
How can we best help the participant enjoy Young Life Activities?
Your answer
If the participant gets overly bothered or irritated, what are some ways to help him/her deal with and redirect his/her behavior?
Your answer
If, as a last resort, discipline is needed, what works and what does not? (If we think discipline is necessary, we will communicate this with you).
Your answer
How do you encourage him or her to take part in a new event that he or she has not done before?
Your answer
T-Shirt Size
XS
S
M
L
XL
XXL
Other:
Clear selection
Other Helpful Comments:
Your answer
A copy of your responses will be emailed to the address you provided.
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