INCLUSIVE FUN

Child’s Name:______________________________________________________________ M_____ F_____

Age:____________ Grade:___________ Birthdate:_____________________________

Address:__________________________________________________________________________________

Postal Code:______________ Home Phone #:________________ Email:____________________________

Medicare #:________________________________ Exp. Date: __________________________________

Mother’s Name:____________________________ Work #:____________________________________

Father’s Name:____________________________ Work #:____________________________________

Are you available to help with transportation? Yes ______ No______

CHILD’S SPECIAL NEED: Please attach additional sheet & info., if necessary.

GENERAL INFORMATION:

Please check:

My child uses: ____ Wheelchair _____Hearing Aids _____Walker _____Orthotics

____Other (Please Specify):_____________________________________________

Does your child have allergies? _____ YES _____ NO

If “Yes”, specify ~ (foods, medication, seasonal): __________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________

Any special instructions regarding allergies:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does you child have seizures? _____ YES _____ NO

If “Yes”, which type:

____________________________________________________________________________________________________________________________________________________________________________________________________

Duration of seizure: _______________________________________________________________________________

Frequency of seizures:_____________________________________________________________________________

Is your child on medication now? _____ YES _____ NO

If “Yes”, do they carry medication with them / require medication nearby?

(Our Staff is not permitted to administer medications to your child ~ arrangements for medication should be made in advance, unless in an emergency situation)

____________________________________________________________________________________________________________________________________________________________________________________

Is there any reason that you would have to limit or restrict activities? _____ YES _____ NO

Please comment:______________________________________________________________________________

__________________________________________________________________________________________

Please check the appropriate:

Vision: ____Good ____Adequate ____Poor ____Unknown

Hearing: ____Good ____Adequate ____Poor ____Unknown

Does your child communicate his / her needs? _____YES _____NO

If “No”, please explain:__________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Is your child able to follow directions? _____YES _____NO

Specify if necessary:____________________________________________________________________________

__________________________________________________________________________________________

How would our staff handle your child’s behavioral difficulties (if any)?

____________________________________________________________________________________________________________________________________________________________________________________

Does your child require a support worker? _____YES _____NO (You must provide your own worker)

Support Worker: ______________________________ Phone #:______________________________

Doctor:_____________________________________ Phone #:______________________________

My Child Enjoys: My Child Dislikes:

__________________________________________ __________________________________________

__________________________________________ __________________________________________

Through Inclusive Fun, I would like to see my child involved in: ____________________________________________________________________________________________________________________________________________________________________________________

Please describe the types of leisure / recreation activities that your child has already been involved in:

____________________________________________________________________________________________________________________________________________________________________________________

Please describe your child’s personality:

____________________________________________________________________________________________________________________________________________________________________________________________________What are your expectations of the Inclusive Fun Program?

____________________________________________________________________________________________________________________________________________________________________________________________________

Outline any other information / special considerations to keep in mind regarding the child that you feel would be beneficial to our staff:

____________________________________________________________________________________________________________________________________________________________________________________________________

***In case of emergency (and unable to contact parents), Please call***:

Name:_______________________________________________

Address:______________________________________________

Phone #:_____________________________________________

PROGRAM PARTICIPATION WAIVER

I, the undersigned, consent to my son/daughter, ____________________________________, to take part in the Inclusive Fun Program for which they are registered, including all activities/events involved in said program. I declare that I have accurately disclosed all information regarding physical, mental or medical conditions affecting the named participant and acknowledge that this information may be used for Parks & Recreation use in the delivery of the Inclusive Fun Program.

I hereby release the Town of Riverview Parks & Recreation Department, its facilities and its personnel from all claims and actions, which my son/daughter or I may have arising out of injury or damage, that we may suffer during the participation in the program for which we are registered. I understand that Parks & Recreation tries to create a safe and controlled environment for participation and that the Department has established rules for participation on and about the Inclusive Fun Program that must be followed by the participant.

I further agree that there will be no claims for any loss of property while participating in any function pertaining to the Summer Programs, which we have registered, conducted by the Riverview Parks & Recreation Department.

Signed: ________________________________________________(Parent / Guardian)