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Inclusion Services

Participant Information Form

Brooklin Community Centre and Library

8 Vipond Road, Brooklin, ON L1M 1B3

905.430.4300 x6520 · whitby.ca/inclusion · inclusion@whitby.ca

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 aecting mobility, communication,

comprehension and or interaction that could eect 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 oered for programs run by the Town of Whitby.

Participant Information - please print

Last Name First Name Age Date of Birth (mm/dd/yyyy)

Participant’s Special Need(s) Provide the course code(s) for the programs(s) you would like

Course Code 1: Course Code 2:

Would you like to be placed on a waitlist for additional programs? Yes No

Emergency Contact #1 Information

Last Name First Name Relation

Family Address Nearest Intersection

City/Town Postal Code Email

Home Phone Cell Phone Work Phone

Emergency Contact #2 Information

Last Name First Name Relation

Family Address Nearest Intersection

City/Town Postal Code Email

Home Phone Cell Phone Work Phone

Emergency Contact #3 Information (Associated with an Agency/Worker)

Name of Agency Name of Worker Phone Number

Medical Information - please print clearly

Participant’s Medical Condition

Physician’s Name Phone Number

If medication is required during program times, a

Medication Administration Request Form must be completed.

Yes No Please initial beside each

Does the Participant have seizures?

If yes, are they controlled by medication?

Please describe the Participant’s seizures (indicate frequency) and how they are handled.

Does the Participant have allergies? If yes, please describe.

Does the Participant have any food restrictions? If yes, please describe.

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

activities.

Yes No

Mobility/Physical

Participant crawls and requires support.

Participant walks independently and does not require support.

Participant walks with aids and requires support.

Participant is mobile with wheelchair and does not require support.

Participant needs assistance when transferring from a wheelchair.

Please describe the Participant’s ne motor skills:

Please describe the Participant’s hearing capabilities:

Please describe the Participant’s visual capabilities:

I authorize sta to assist the Participant with any transfer/mobility needs.

Yes No

Activities of Daily Living/Basic Care

Participant can eat and drink independently and does not require support.

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

Participant can use the washroom independently and does not require support.

Participant wears diapers and requires support.

Participant needs assistance with getting on/o the toilet.

I authorize sta to assist the Participant with any toileting needs.

Yes No

Communication/Comprehension Additional Notes

Participant understands verbal conversation.

Participant can follow simple instructions.

Participant understands 2-3 ideas in a

sentence.

Participant is able to follow verbal instructions.

Participant has a picture book that they

regularly use for communication at home

and/or at school.

Participant participates in conversation.

Yes No

Expresses him/herself by using Additional Notes

Words

Sounds

Gestures

Singing

Pictures / Communication Board

Usually Sometimes

Rarely

Social Development Additional Notes

Participant has a hard time dealing with transitions.

Participant cooperates with leaders.

Participant cooperates with selected others in group.

Participant is willing to participate in new situations.

Participant prefers to be alone - displays

intermittent social withdrawl.

Participant prefers being with sta/adults.

Participant prefers being with friends/peers.

Participant relates to peers.

Participant can interact socially with peers.

Participant readily participates in small groups.

Participant can control their emotions.

Participant uses coping skills to manage their

emotions.

Behaviour:

Yes No

Does your child have a tendency to be... Additional Notes

Withdrawn

Sensitive

Self condent

Enthusiastic

Social

Outgoing

Moody/Unpredictable

Attention seeking

Easily frustrated

Verbally aggressive

Physically aggressive towards others

Aggressive towards self

Yes No Does the Participant...

Display disruptive or inappropriate behaviour? 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? If so, what factors cause the

Participant to become frustrated? What behaviours are exhibited? How would you like Sta

to react when the Participant is frustrated?

Yes No Does the Participant...

Receive additional support at school? 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? If so, how would you like us to deal with this?

Environmental Concerns

Please list any routines/patterns:

Please list any personal space issues:

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

Please list any xations (i.e. water):

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

Needs

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

What is the best way to communicate with and provide instructions to the Participant?

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

What are your (parent/guardian) expectations for accomplishments?

Participant’s Interests

Likes/dislikes and favourite activities:

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 sta 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 sta 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 signicantly dierent than what was disclosed

on the Participant Information Form; or,

• If a Participant injures a sta 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 sta 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.

I/We, __________________________, understand that the safety of participants and sta is the Town of

Whitby’s top priority. I/We understand that in circumstances where the safety of participants and/or sta 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.

Parent/Guardian Signature: Date: (dd/mm/yyyy)

To be completed by sta

Yes No

Meets participation criteria (Circle one)

Program Requested:

Program Recommended:

Sta Support:

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