Inclusion Support Request Form

Submitted by*

E-mail Address (for confirmation)*

Date Submitted*

Season*

Year

Participant's Name*

Date Of Birth*

Participant Gender

Male
Female

Parent/Guardian Name*

Parent/Guardian Email*

Parent/Guardian Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Park District*

Is the participant a resident or non-resident of your park district?*

Which park district does the participant live in?*

Program Supervisor*

Program Supervisor Email*

Program Title*

Did you confirm with the parent/guardian that they would like support for this particular program?*

Yes
No

Program Number

Program Location - include room/field number

Day of Week*

Program Time*

Date Program Begins*

Date Program Ends*

Does not meet on

Name of Instructor

Date individual signed up for this program*

Please indicate below, which type of assistance is requested

Training
Additional Staff
Modified Equipment
Other
Observation (reminder--there is a separate observation form)

Additional Comments

Is the participant registered for a second program?*

Program Supervisor (2)*

Program Supervisor Email (2)*

Program Title (2)*

Did you confirm with the parent/guardian that they would like support for this particular program (2)?*

Yes
No

Program Number (2)

Program Location (2) - include room/field number*

Day of Week (2)*

Program Time (2)*

Date Program Begins (2)*

Date Program Ends (2)*

Does not meet on (2)

Date individual signed up for program (2)

Additional Comments (2)

Is the participant registered for a third program?*

Program Supervisor (3)*

Program Supervisor Email (3)*

Program Title (3)*

Did you confirm with the parent/guardian that they would like support for this particular program (3)?*

Yes
No

Program Number (3)

Program Location (3) - include room/field number*

Day of Week (3)*

Program Time (3)*

Date Program Begins (3)*

Date Program Ends (3)*

Does not meet on (3)

Date individual signed up for program (3)

Additional Comments (3)

Is the participant registered for a fourth program?*

Program Supervisor (4)*

Supervisor Email (4)*

Program Title (4)*

Did you confirm with the parent/guardian that they would like support for this particular program (4)?*

Yes
No

Program Number (4)

Program Location (4) - include room/field number*

Day of Week (4)*

Program Time (4)*

Date Program Begins (4)*

Date Program Ends (4)*

Date individual signed up for program (4)

Does not meet on (4)

Additional Comments (4)

Are Parents Aware of WDSRA Services?

Yes
No