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Inclusion Form

Inclusion Formwdsra-admin2019-03-18T06:32:19+00:00

Inclusion Notification Form

WDSRA Mission: The development of individuals through recreation

WDSRA Vision: Opening a world of untapped potential and a lifetime of possibilities

Questions regarding this form should be directed to Tammy Kerrins at 630-681-0962
or e-mail tammyk@wdsra.com.

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

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116 N. Schmale Road
Carol Stream, IL 60188-2103
P: 630-681-0962
F: 630-681-1262
info@wdsra.com

About Us
WDSRA Programs
Park District Programs – Inclusion
Program Guide For New Parents
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