Inclusion Support Request Form

Submitted by*

E-mail Address (for confirmation)*

Date Submitted*

Season*

Year

Participant's Name*

Date Of Birth*

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*

Date Program Ends*

Does not meet on

Name of Instructor

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

Date Program Ends 2

Does not meet on 2

Please indicate below, which type of assistance is requested 2

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

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

Date Program Ends 3

Does not meet on 3

Please indicate below, which type of assistance is requested 3

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

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

Date Program Ends 4

Does not meet on 4

Please indicate below, which type of assistance is requested 4

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

Additional Comments 4

Are Parents Aware of WDSRA Services?

Yes
No