Special Needs Youth Program Accommodation Consent Form

Youth Information

Name of Youth: Date of Birth: Parent/Guardian Name: Contact Phone: Contact Email:

Program Information

Program Name: Program Dates:

Special Needs & Accommodation Details

Diagnosis/Disability (if applicable): Please describe the specific accommodations, supports, or modifications needed: Allergies/Medical Concerns: Medications (with instructions):

Consent

I, the undersigned parent/guardian, consent to the participation of my child in the indicated youth program and authorize the implementation of the accommodations described above. I have provided accurate and complete information to ensure the safety and inclusion of my child.

Parent/Guardian Signature: Date: