Required fields are marked with asterisks (*)

Inclusion Services Participant Information Form

Town of Whitby
Brooklin Community Centre and Library
8 Vipond Road, Brooklin, ON L1M 1B3
905.655.2010 • inclusion@whitby.ca • whitby.ca/inclusion

The information captured in this form will be emailed directly to the Town’s Inclusion Services Team, where it will be securely stored.

The child must meet the following criteria to be eligible for additional support:

Participant must be a Whitby resident.
Participant has a physical, developmental and/or learning disability affecting mobility, communication, comprehension and or interaction that could effect their safety of other participants.
Participant requires extra support/assistance at home or at school for basic care such as dressing or toileting.
Inclusion Services are only offered for programs run by the Town of Whitby.

Participant Information

Last Name

First Name

Age

Date of birth

Describe any other health problems that may restrict the Participant’s participation and/or performance in activities.

Participant's Special Need(s)

Parent/Guardian Full Name

Parent/Guardian Phone Number

Parent/Guardian Email Address

Emergency Contact #1 Information

Last Name

First Name

Relation

Family Address

Nearest Intersection

City / Town

Postal code

Home Phone

Cell Phone

Work Phone

Mobility / Physical

Participant crawls and requires support

Yes

Participant walks independently and does not require support

Yes

Participant walks with aids and requires support

Yes

Participant is mobile with wheelchair and does not require support

Yes

Participant needs assistance when transferring from a wheelchair

Yes

I authorize staff to assist the Participant with any transfer/mobility needs

Yes

Please describe the Participant’s fine motor skills:

Please describe the Participant’s hearing capabilities

Please describe the Participant’s visual capabilities

Activities of Daily Living/Basic Care

Participant can eat and drink independently and does not require support

Yes

Participant can dress himself/herself independently and does not require support

Yes

Participant wears diapers and requires support

Yes

I authorize staff to assist the Participant with any toileting needs

Yes

Does your child have a tendency to be...

Withdrawn

Yes

Additional Notes

Sensitive

Yes

Additional Notes

Self confident

Yes

Additional Notes

Enthusiastic

Yes

Additional Notes

Social

Yes

Additional Notes

Outgoing

Yes

Additional Notes

Moody/Unpredictable

Yes

Additional Notes

Attention seeking

Yes

Additional Notes

Easily frustrated

Yes

Additional Notes

Verbally aggressive

Yes

Additional Notes

Physically aggressive towards others

Yes

Additional Notes

Aggressive towards self

Yes

Additional Notes

Does the Participant...

Display disruptive or inappropriate behaviour

Yes

If so, indicate the nature of behaviour and what techniques teachers and family use to deal with it.

Find that certain activities cause them to become frustrated

Yes

If so, what factors cause the Participant to become frustrated? What behaviours are exhibited? How would you like Staff to react when the Participant is frustrated?

Receive additional support at school

Yes

If so, what kind of support? Have any established routines/strategies/activities that could assist them in a recreation setting? If so, what are they?

Wander or run from group activities

Yes

If so, how would you like us to deal with this?

Environmental Concerns

Please list any routines/patterns

Please list any fears (i.e. loud noises)

Please list any fixations (i.e. water)

Please list any safety concerns (i.e. no concept of safety/fear, medical or environmental concerns)

Communication/Comprehension

Participant understands verbal conversation

Yes

Additional Notes

Participant can follow simple instructions

Yes

Additional Notes

Participant understands 2-3 ideas in a sentence

Yes

Additional Notes

Participant is able to follow verbal instructions

Yes

Additional Notes

Participant participates in conversation

Yes

Additional Notes

Expresses him/herself by using ...

Words

Yes

Additional Notes

Sounds

Yes

Additional Notes

Gestures

Yes

Additional Notes

Singing

Yes

Additional Notes

Pictures / Communication Board / Tablet

Yes

Additional Notes

Social Development

Participant has a hard time dealing with transitions

Usually

Sometimes

Rarely

Additional Notes

Participant cooperates with leaders.

Usually

Sometimes

Rarely

Additional Notes

Participant cooperates with selected others in group

Usually

Sometimes

Rarely

Additional Notes

Participant is willing to participate in new situations

Usually

Sometimes

Rarely

Additional Notes

Participant prefers to be alone - displays intermittent social withdrawal

Usually

Sometimes

Rarely

Additional Notes

Participant prefers being with staff/adults

Usually

Sometimes

Rarely

Additional Notes

Participant prefers being with friends/peers

Usually

Sometimes

Rarely

Additional Notes

Participant can interact socially with peers

Usually

Sometimes

Rarely

Additional Notes

Participant readily participates in small groups

Usually

Sometimes

Rarely

Additional Notes

Participant can control and manage their emotions

Usually

Sometimes

Rarely

Additional Notes

Consent to Care

Changing/Dressing (ie. assist in putting on bathing suit for swimming)

Yes

Other:

Yes

Please specify (if Other)

Special Instructions

Please list any personal space issues

Needs

What needs does the Participant have in relationship to their participation in the recreation program

What goals would the Participant be striving towards in the program and how can we help

Participant’s Interests

Likes/dislikes and favourite activities

Good incentives for your child (stickers, fidget toys, favourite character etc.)

Previous recreation activities

Involvement in activities outside of school/work

Any activity restrictions or limitations

Swimming experience/ability - any adverse reaction to temperature change

How will the Participant access the program? (bus, car, other)

Additional Comments or Concerns

Safety in the Town of Whitby’s Recreation Programs Safety is our number one concern at the Town of Whitby. We need to consider the safety of every participant and staff member when determining a Participant’s eligibility and continued participation in our programs. The Town of Whitby reserves the right to refuse a Participant’s registration or require a Participant to withdraw from a program based on any one of the following:

Participant does not meet the criteria;
Participant’s needs cannot be safely met;
Participant poses a danger to themselves or others;
Town of Whitby staff are unable to meet the care level required to ensure the Participant’s safety and success in the program;
Participant’s medical/physical/behavioural condition is significantly different than what was disclosed on the Participant Information Form; or,
If a Participant injures a staff member or another participant, the Participant will be sent home immediately. In order to return to the program, a plan will be put in place by the Supervisor (or designate) in consultation with the parents/guardians to ensure a safe environment for the staff and participants. If, upon return, a second incident occurs, the Participant will be removed from the program unless outside support is provided by the parents/guardians.

Acknowledgement

I understand that the safety of participants and staff is the Town of Whitby’s top priority. I/We understand that in circumstances where the safety of participants and/or staff is compromised, the Town of Whitby has the right to remove the Participant from the program.

Freedom of Information Act
Personal information on this form is collected under the authority of Section 11 of the Municipal Act, SO 2001, c.25 and will be used for the registration purposes in requesting recreation program(s). Questions regarding the collection of personal information should be directed to the Manager of Recreation, 500 Victoria Street West, Whitby, ON L1N 9G4.

Form Builder

Inclusion Services Participant Information Form

Participant Information

Emergency Contact #1 Information

Mobility / Physical

Activities of Daily Living/Basic Care

Does your child have a tendency to be...

Does the Participant...

Environmental Concerns

Communication/Comprehension

Expresses him/herself by using ...

Social Development

Consent to Care

Needs

Participant’s Interests