Inclusion Form

Submitted by*

E-mail Address (for confirmation)*

Date Submitted*

Season*

Year

Participant's Name

Date Of Birth*

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

Minimum Age

Maximum Age

Staff/Participant Ratio

Name of Instructor

Class Prerequisites?

Equipment/Supplies Needed

Please indicate below, which type of assistance is requested

Additional Comments

Are Parents Aware of WDSRA Services?

Inclusion Notification Form