Inclusion 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-(Do not enter for observations)

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

Minimum Age

Maximum Age

Staff/Participant Ratio

Name of Instructor

Class Prerequisites?

Equipment/Supplies Needed

Please indicate below, which type of assistance is requested

Training
Observation
Additional Staff
Modified Equipment
Other

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

Minimum Age 2

Maximum Age 2

Staff/Participant Ratio 2

Name of Instructor 2

Class Prerequisites? 2

Equipment/Supplies Needed 2

Please indicate below, which type of assistance is requested 2

Training
Observation
Additional Staff
Modified Equipment
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

Minimum Age 3

Maximum Age 3

Staff/Participant Ratio 3

Name of Instructor 3

Class Prerequisites? 3

Equipment/Supplies Needed 3

Please indicate below, which type of assistance is requested 3

Training
Observation
Additional Staff
Modified Equipment
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

Minimum Age 4

Maximum Age 4

Staff/Participant Ratio 4

Name of Instructor 4

Class Prerequisites? 4

Equipment/Supplies Needed 4

Please indicate below, which type of assistance is requested 4

Training
Observation
Additional Staff
Modified Equipment
Other

Additional Comments 4

Are Parents Aware of WDSRA Services?

Yes
No

Inclusion Notification Form