Inclusion Support Request Form

WDSRA Mission: We enrich lives, connect communities and create fun through inclusive recreational opportunities.

WDSRA Vision: A world of opportunities, belonging and individuals reaching their full potential.

Questions regarding this form should be directed to Maddy Manden at 630-681-0962
or e-mail maddym@wdsra.com.

Submitted by*
E-mail Address (for confirmation)*
Date Submitted*
MM slash DD slash YYYY
Season*
Year
Participant's Name*
Date Of Birth*
MM slash DD slash YYYY
- Male
- Female
Parent/Guardian Name*
Parent/Guardian Email*
Parent/Guardian Phone*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Park District*
Supervisor*
Supervisor Email*
Program Title*
Program Number
Program Location (include Rm #)
Day of Week*
Time*
Date Program Begins*
MM slash DD slash YYYY
Date Program Ends*
MM slash DD slash YYYY
Does not meet on
Name of Instructor
Date individual signed up for this program*
MM slash DD slash YYYY
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?*
Supervisor program 2*
Supervisor 2 Email*
Program Title 2*
Program Number 2
Program Location 2 (include Rm #)*
Day of Week 2*
Time 2*
Date Program Begins 2*
MM slash DD slash YYYY
Date Program Ends 2*
MM slash DD slash YYYY
Does not meet on 2
Date individual signed up for program 2
MM slash DD slash YYYY
Additional Comments 2
Is the participant registered for a third program?*
Supervisor program 3*
Supervisor 3 Email*
Program Title 3*
Program Number 3
Program Location 3 (include Rm #)*
Day of Week 3*
Time 3*
Date Program Begins 3*
MM slash DD slash YYYY
Date Program Ends 3*
MM slash DD slash YYYY
Does not meet on 3
Date individual signed up for program 3
MM slash DD slash YYYY
Additional Comments 3
Is the participant registered for a fourth program?*
Supervisor program 4*
Supervisor 4 Email*
Program Title 4*
Program Number 4
Program Location 4 (include Rm #)*
Day of Week 4*
Time 4*
Date Program Begins 4*
MM slash DD slash YYYY
Date Program Ends 4*
MM slash DD slash YYYY
Date individual signed up for program 4
MM slash DD slash YYYY
Does not meet on 4
Additional Comments 4
Are Parents Aware of WDSRA Services?
- Yes
- No
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