Participant Intake Form

Please fill out this intake form to learn more about becoming a participant ages 3-18.

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 as well as group settings.

Participant Intake Form

Participant Name(Required)

First Last

Participant Birth Date(Required)

Participant Disability(Required)

Participant City of Residence(Required)

Primary Contact Name(Required)

First Last

Primary Contact Email(Required)

Primary Contact Cell Phone(Required)

How did you hear about Youth Challenge?(Required)

Today's Date(Required)

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Participant Intake Form

Participant Intake Form