Inclusion Notification Form

Submitted by:         E-mail Address (for confirmation):

Park Dist Staff     or Parent/Guardian

Date Submitted:                  Season: Please Choose Winter Spring Summer Fall   Year: Please Choose 2012

Participant's Name:         Date of Birth:    Male Female

Parent's Name:    Phone Number:    Parent email:

Address:        City:               Zip:

Park District: Please Choose Bloomingdale Carol Stream Glen Ellyn Naperville Roselle Warrenville West Chicago Wheaton Winfield              Supervisor:

Program Title:             Program Number:

Program Location (include Rm #):

Day of Week:                Time:

Date Program Begins:     Date Program Ends:     Does not meet on:

Minimum Age:            Maximum Age:           Staff/Participant Ratio:

Name of Instructor:       Class Prerequisites?

Equipment/Supplies Needed:

Additional Comments:

Are Parents Aware of WDSRA Services?