Inclusion Participation Form

Participants registering in one-to-one support or adapted programs are asked to complete the Inclusion Participation Form to provide additional information on their support needs. The below form provides our staff with the necessary information to best support participants in adapted or integrated programs.

Questions about this form may be directed to Crystal Kort, Recreation Programmer, One-to One-Support, at (705) 739-4220 x4773 or crystal.kort@barrie.ca.

Form submissions are confidential and will only be provided to the staff working directly with a participant in a program. Hard copies of the foem are available to complete at Allandale Community Centre, East Bayfield Community Centre, Peggy Hill Team Community Centre and Parkview 55+ Centre.

 

General Participant Information

Name
Caregiver's Name
Address

Emergency Contact Information

Participant Information

Communication

1. How does the participant communicate their needs and wants?
2. What is the best way to give instructions?

Behavioural Supports/ Safety Concerns

1. Does the participant commonly display self-injurious behavior?
2. Are there any circumstances in which the participant may become physically aggressive?
3. Is the participant likely to wander or run away?
4. Does the participant engage in any self stimulating/regulating behaviors?
5. Is aggression towards others, peers and/or adults, a common occurrence with the participant?
6. Are there any behaviors that are inappropriate and/or you do not want to encourage?
7. Do you have concerns about the participant around water (e.g., pools or lakes?

Personal Care

How much assistance is a required field for:
1. Changing/ Dressing?
2. Diaper/Toileting?
3. Eating/ G Tube or any Dietary Considerations?
4. Mobility/ Assistive Devices (hearing aids, glasses, crutches, braces, etc.)
5. Transfers/ Weight Bearing

Additional Information

Consent to Share Information

, parent/guardian, give my consent for the recipient of this document to collect, use and disclose information regarding my child , for the purpose of developing and implementing an Inclusive Recreation Plan. Without limiting the generality of the foregoing, I expressly consent to the exchange of information, including the information contained in this form, personal health information regarding my child, with any organization as may be reasonably necessary for the purpose of developing an Inclusive Recreation Plan, including but not limited to the following entities, their associates and affiliates: Inclusive Recreation Services, Catulpa Community Support Services, Behaviour Management Services of York and Simcoe, Kidz "n" Sports, Community Care Access Centre, Children's Treatment Network, Simcoe Community Services and New Path Child and Youth Services.