2026 Health Form

Guardian Information
Guardian Name*

First NameLast Name
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Household Income*
This is used for reporting for grants. Please type N/A if you would prefer not to answer.
# of Individuals in Household*
This is used for reporting for grants. Please type N/A if you would prefer not to answer.
Yes
Updates to Information

If at any point your information changes (phone number, health needs, etc.), please reach out to provide updates that we can manage on the back end. You do not need to fill out this form every time something changes.
Emergency Contact Info

In the event of an emergency where the guardian is not present or is unable to make decisions or manage the participants' health and safety, the individual listed below will be contacted, informed of the situation, and asked to pick up the participant from the program.
Emergency Contact Name*

First NameLast Name
Relationship to the Participant*
Emergency Contact Phone Number*
Format: (000) 000-0000.
YesNo

Health History

The information provided in this section may be shared with specific parties as needed to support the participant’s safety and accommodations. For example, volunteers working one-on-one with the participant may need to understand limitations, and emergency responders may require medical history to provide appropriate care if a guardian is not present.
Does the participant have range of motion limitations? If yes, please describe.*
Does the participant use any adaptive devices (wheelchair, braces, etc.)?*
If the participant uses a wheelchair, please indicate to what extent.*
If the participant uses a wheelchair, can they transfer independently to other chairs/to and from the ground?*
Does the participant need assistance walking/ambulating?*
Does the participant have any allergies (environmental, medication-related, food, etc.)? If yes, please list each allergy, the type of exposure that triggers a reaction (e.g., airborne, ingestion), the severity of the reaction, and the appropriate treatment if exposure occurs.*
For example: Peanut allergy, breaks out in hives when eaten, needs to use her epi-pen
Is the participant prescribed an inhaler, insulin, EpiPen, or any other emergency medication? If yes, please confirm that the medication will be available during programs and that the participant can use it independently, or that a supervising guardian is able to administer it if needed.*
Does the participant have any chronic illnesses, medical conditions, or physician-recommended activity limitations that could affect their participation in programs? If yes, please describe these conditions and limitations.*
Is the participant currently taking any prescribed medications? Please note that CTHF staff and volunteers are not authorized to administer medications to participants, prescribed or otherwise.*
This will only be shared with medical personal if medical treatment is needed and a guardian is not present to answer questions/provide this information.
Does the participant use a catheter?*
If the participant uses a catheter, can they maintain/use it on their own with assistance from an adult?*
Does the participant need assistance using the restroom?*
Insurance Carrier Name*
Policy Holder Name*
Policy Number*
Group Number*
Copy of Insurance Card*

Cancelof
Yes, I understand and will provide a caregiver at all programs should my participant need support in any of these areas.

Behavior & Dietary Needs

The information provided in this section will be shared with certain parties as needed to support the participant’s experience at programs.
Please tell us about the participant's communication level (verbal, written, how clearly their communication can be understood by volunteers, etc.).*
Does the participant have any behaviors/triggers the staff and volunteers need to be aware of? If yes, are there certain coping mechanisms or practices that they are working on that should be encouraged as a tool to redirect behavior?*
What is the best way to assist the participant if they become overwhelmed or upset?*
Does the participant have trouble with transitions (wrapping up one activity to start another one)? If so, how can we make transitions easier for them?*
Snacks and water are typically available at programs. Please describe any allergies or dietary restrictions the participant has.*
Note that certain allergies or dietary restrictions may not be something we can accommodate at all programs. Call us to discuss what allergies/restrictions we can accommodate.

Consent Forms
Behavior Agreement

I understand that Carrie Tingley Hospital Foundation and its program partners are dedicated to providing a safe, fun, and inclusive environment for all participants. To ensure a positive experience, I understand that my participant and any guardians staying to support my participant must follow the behavior expectations outlined below:

Kindness & Inclusion - participants should be kind, inclusive, and use respectful language. Bullying, teasing, or exclusion will not be tolerated.

Following Directions - participants must follow directions provided by staff and volunteers. Participants that refuse to follow directions may be asked to step out of the activity for their own safety/the safety of others.

Respect for Property - participants should be respectful of the facilities in use, as well as all equipment provided for the program. Misuse of equipment and facilities will not be tolerated and may result in being asked to leave the program.

Safe Spaces - pets, weapons, cigarettes, vapes, alcohol, drugs and other paraphernalia are not permitted at our programs. Participants found to have brought any of these types of items may be asked to leave the program.
Medical Release and Authorization

As the parent and/or legal guardian of the named participant, I hereby authorize the staff, volunteers and program partners of the Carrie Tingley Hospital Foundation to provide basic medical care, such as first aid or CPR, if the need arises during programs my participant attends. I understand that staff and volunteers will only administer care for which they have received proper training and certification from a recognized accrediting body.

If the participant requires medical treatment beyond basic care, they may only be transported by a legal guardian, an emergency contact, or professional emergency services (e.g., ambulance, life-flight). I acknowledge that staff, volunteers and partners of the Carrie Tingley Hospital Foundation will not transport the participant to an urgent care center, emergency room, or any other medical facility.

In the event that emergency medical care is necessary, every reasonable effort will be made to contact the parent/guardian listed on this form. If no response is received, the emergency contact will be notified. If neither the guardian nor the emergency contact can be reached, I understand that the Carrie Tingley Hospital Foundation may contact professional emergency services to transport the participant elsewhere for medical evaluation and treatment.

I acknowledge that all medical expenses incurred as a result of illness or injury during participation in these programs are the sole financial responsibility of the participant's parent/guardian and/or their health insurance provider. I release and hold harmless the Carrie Tingley Hospital Foundation, its staff, volunteers, and affiliates from any claims, liabilities, or expenses arising from medical care provided in good faith under this authorization.
Informed Consent

I, the undersigned parent and/or legal guardian, hereby give my consent for the named individual to participate in all activities organized by the Carrie Tingley Hospital Foundation and/or their program partners during programs they are registered for. In consideration of the individuals' participation, I voluntarily assume all risks and hazards associated with these activities, including but not limited to those occurring during travel to and from program sessions.

I hereby release, indemnify, and hold harmless the Carrie Tingley Hospital Foundation, its officers, agents, representatives, volunteers, program partners, and any affiliated entities from any and all liability for injuries, damages, or losses incurred by the individual as a result of participation in program activities.

I acknowledge and understand that participation in physical activities, including adaptive sports and activities, carries inherent risks. These risks may include, but are not limited to, sprains, fractures, paralysis, or other serious injuries, including death. I further waive any claims against the Carrie Tingley Hospital Foundation, its staff, volunteers, sponsors, advertisers, program partners, and, if applicable, property owners or lessors of program venues.

I understand that some information submitted in this form will be shared with staff/volunteers/program partners/emergency personnel that will be working directly with the individual listed on this form. I understand that the purpose of this information being shared with relevant parties is to support specific needs or accommodations the individual may require.

Photo/Video Waiver

In consideration of the individuals' participation at Carrie Tingley Hospital Foundation programs, or programs hosted by the Foundations' partners, I hereby grant permission to Carrie Tingley Hospital Foundation's staff and affiliates to utilize the participants' appearance, performance and/or voice in published media for the purpose of promotion, reporting or publication related to the organization. I understand that no royalty, fee or any other compensation of any kind shall become payable to me for the organizations use of the individuals' appearance, likeness, voice, etc. There is no time limit on the validity of this release, nor is there any geographic limitation on where these materials may be distributed.
Confirmation

By signing and dating below, I confirm that the information provided on this form is true and accurate to the best of my knowledge. By signing and dating below, I agree to abide by the waivers and releases listed above. I acknowledge that by submitting my electronic signature, it carries the same legal effect as a handwritten signature and is equally binding.
Signature*

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2026 Participation Form

Participant Information

Guardian Information

Updates to Information

Emergency Contact Info

Program Registration

Large-Scale Program Note

Health History

Behavior & Dietary Needs

Consent Forms

Confirmation