Inclusion Services Form
Date of Request
-
Month
-
Day
Year
Please complete one request form for every program the individual has registered for.
Participant Information
Participant Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Disability/Diagnosis
Parent/Guardian
Phone Number
*
E-mail
example@example.com
Program Information
Program Title
Program Start Date
-
Month
-
Day
Year
Date
Program Time
Hour Minutes
AM
PM
AM/PM Option
Program Location
Instructor
Please confirm that you are requesting a LEISURE BUDDY.
Yes
No
Additional Participant Information
For any questions or concerns, please contact Program Manager, Jake Pawlak, 630-953-2371 or jpawlak@lombardparks.com.
Following the requested form, NEDSRA will contact the Program Manager listed above to discuss the recommended inclusion plan. Please note, if the Leisure Buddy is recommended in the inclusion plan, adequate time will be needed to secure and train a staff member.
Submit
Should be Empty: