Registration Form
Please fill this form out with the PARTICIPANT THAT WILL ATTEND PROGRAM information. At Danvers Recreation we want every participant to have an opportunity to experience our programs. Julia Ryan is the new Certified Therapeutic Recreation Specialist (CTRS) on our recreation team. Her role is to assist in providing accommodations and services for individuals who may need them to enhance program participation. A meeting may be requested in person to learn more about you/your participant and their needs. Please note that the recreation department may not be able to accommodate every participant's needs, but we will try our best in every case. Please fill out this form in its entirety, the more information the better! Access to confidential information is restricted to authorized personnel and will only be shared with relevant parties as necessary to support care and services. Whether you are the participant, or you are filling this form out on behalf of the participant, please be honest and complete to the best of your ability. This information will be valid for 2 years, unless there is a significant change in any aspect. Reach out with any questions to juliaryan@danversma.gov.
Participant Name
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First Name
Middle Name
Last Name
Birth Date
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 -
Month
 -
Day
Year
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Gender:
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Grade (Grade entering if it's currently summer)
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Please Select
Pre-school
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Transitional Program (Typically 18-22)
Post High School
Languages spoken at home (list primary first):
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred E-mail
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example@example.com
Preferred Phone Number
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Primary phone number
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Emergency Contact
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First Name
Middle Name
Last Name
Emergency Contact Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone Number
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Primary phone number
Format: (000) 000-0000.
Relationship to participant
*
Mother, Father, Guardian, etc.
Secondary Emergency Contact
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First Name
Middle Name
Last Name
Second Emergency Contact Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Second Emergency Contact Phone Number
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Primary Phone Number
Format: (000) 000-0000.
Relationship to participant
*
Mother, Father, Guardian, etc.
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General Information
This section is to provide any information that may allow the CTRS to learn more about the participant and how to provide support in the best way.
Participant's diagnosis and/or nature of needs?
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Please include any mental health diagnoses.
Has participant been involved in Danvers Recreation before?
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Yes
No
Unsure
Please describe your experience in the past with Danvers Recreation:
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Tell us about the participant. Please include any information that may be beneficial to our staff while they participate in our programs:
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Please list your participant's strengths and struggles in any aspect (physical, emotional, social, behavioral, etc.):
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Ex: Listening, communication, personal space, cleaning, sharing, step directions, etc.
Please list at least 1 participant goal in our recreation programs:
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Participant's likes and dislikes:
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Type of support participant typically receives (in school, at home, or other activities). Please check all that may apply:
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Group/Social Support
1:1 Support
Activities of Daily living/Medical support/Full support
Unsure
Other
In the case of an emergency, please indicate participant's level of independence:
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Complete independence
Able to answer yes/no questions
Limited verbal/communication skills
Does not communicate verbally
Other
Any special instructions or comments for staff regarding inclusion support for participant:
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Will a private aid, specialist, or therapist accompany your participant to our programs? *Please note we are currently not staffed for a 1:1 ratio*
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Yes
No
Unsure
If yes, I will provide specialist's contact information and schedule of accompaniment with my child to the therapeutic recreation administrative staff. I understand that they will be required to complete a successful CORI background check at least 2 weeks prior to the beginning of the program they will be attending. I further understand that the specialist accompanying my child must also complete a brief orientation with the CTRS on staff and must complete and sign the Direct Service Professional Packet prior to being allowed to attend programs.
I understand the above conditions and will provide the information necessary to said professional
I will provide (or) hereby give permission for my child's teacher to release his/her Individualized Education Plan to the Danvers Recreation Department, (as well as provide written or verbal communication) for use by the CTRS and recreation staff.
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Yes
No
N/A
Teacher name
First Name
Last Name
Teacher email
example@example.com
I will provide (or) hereby give permission for my child’s provider (ABA therapist, BCBA, Direct Support Provider, etc) to provide written or verbal communication to the Danvers Parks and Recreation Department for use by the Therapeutic Recreation Specialist, Recreation Therapist and Inclusion Staff.
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Yes
No
N/A
Provider name:
First Name
Last Name
Provider Phone Number:
Office phone number
Format: (000) 000-0000.
Provider email:
example@example.com
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Physical Health Information
Please list any medical conditions staff should be aware of:
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Please list any medications that may need to be administered during programs:
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Please list all known allergies for participant:
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What medications does participant regularly take? Please describe dosage, time of day, possible side effects, etc:
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Please list any rescue medications participant may need administered (EpiPen, Inhaler, seizure medication):
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Please list any dietary restrictions/special dietary instructions participant may have:
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Please list any mobility concerns/restrictions participant may have:
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Please indicate which of the following aids participant uses, if any:
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Crutches
Wheelchair
Walker
Cane
AFO (Ankle-foot orthoses)
Other
None
Does participant have any motor impairments?
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Yes
No
Does participant have any visual or auditory impairments?
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Visual
Auditory
None
Does participant experience seizures?
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Yes
No
Please describe last known seizure, known triggers, if anything helps, what medications are used if any, and any other information that may be helpful in the case of a seizure.
Does participant require assistance with any of the following activities of daily living (ADLs), please choose all that apply:
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Dressing
Toileting
Feeding
Mobility
None
Other
Please describe ADL assistance needed:
Any other physical wellness information that may be necessary for recreation staff to know/utilize:
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Cognitive Health Information
Is participant nonverbal?
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Yes
No
If yes, how does participant communicate?
Communication boards, pointing, yes or no labels, pictures, typing/writing, etc.
How many step-by-step directions can participant follow when orally given? (Spoken step-by-step instructions)
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1 step
2 steps
3 steps
Needs constant instruction/full prompting assistance
Can follow any number of given instructions
Other
Can participant read and write? Please check any that may apply:
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Yes can read
Yes can write
No cannot read
No cannot write
Other
Can participate read at current grade level?
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No, reads lower
Yes, reads at or above level
N/A cannot read
How does participant learn best? Please select all that apply:
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Visual
Auditory
Modeling
Tactile
Reading and writing
Other
Are there any concepts that participant struggles with? Please explain:
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Cleaning, sharing, counting, etc.
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Social and Emotional Health Information
Please describe participant’s social behavior:
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Will participant initiate interactions with other children?
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Yes, with everyone
Yes, only with familiar peers
Yes, with support
No, will not initiate with other children
Other
Will participant initiate interactions with adults?
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Yes with everyone
Yes only with familiar peers
Yes with support
No, will not initiate with other children
Other
Will participant discuss non-preferred topics?
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Yes, will talk about anything
Sometimes, if another topic is brought up
Only likes to talk about preferred topics
Other
Is participant aware when someone is bullying or when someone is being unkind?
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Yes, and will tell staff
Yes, but won't tell staff
No, is not aware
Other
How can our staff best support the participant socially? What do you do at home to offer support? What strategies seem to work the best?
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Does your participant have any psychological, emotional, or behavioral concerns that may arise during social situations, new experiences, physical exertion, or stressful circumstances? (Including but not limited to anxiety, aggression, defensiveness, panic attacks, confusion, etc.)
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Describe the participant's relationship with themselves. Is there anything they struggle with? (Ex: what is their self-confidence like? Their self-esteem? Do they engage in negative self-talk? Are they especially tough on themselves?)
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What emotions are we most likely to see from the participant in common situations (meeting someone new, a stressful situation, a funny situation, at drop-off, when they lose a game)?Are they able to recognize and name their emotions?
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Does your participant use coping strategies/grounding techniques? (Sensory techniques/toys and fidgets, calm down routine, choice wheel/sheet, zones of regulation, breathing techniques, calm apps/music, etc.)
*
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Behavioral Health Information
Does participant have a tendency to bolt, wander, or walk away? If yes, please explain:
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Is there a chance of aggression towards themselves or other children/staff? If yes, please explain:
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Will participant speak up about needing to use the bathroom? Please explain:
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Will participant speak about needing a break from an activity or socially? What are some signs participant may need a break?
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Does participant follow rules (rules for games/activities, or if staff ask them not to do something)? Please explain:
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Can participant manage their own things? Will they be able to keep track of their belongings? Please explain:
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Please describe what participant's attention span is like (short attention span, able to focus on one thing for a long period of time, etc.):
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What types of settings is participant UNCOMFORTABLE with? Please select all that apply.
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Uncomfortable around water
Uncomfortable around/on pavement
Uncomfortable around loud areas
Comfortable around all areas
Other
How does participant handle transitions? Is there anything you do at home to help prepare or move transitions forward?
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Tools used for transitions/breaks/activities? Please check all that apply:
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Timers
Reinforcement System
Positive Verbal Praise
Schedules
Social Stories
Verbal Warnings/Reminders
Sensory Items
Frequent Breaks
Other
None
Is participant sensory sensitive and/or sensory seeking? Or have history of sensory seeking/avoiding?
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Sensory sensitives are sights, sounds, tastes, smells, touch, and pains that may be difficult for the participant to process. Examples: loud noises, strong smells. Sensory seeking is any sense that the participant actively seeks out. Examples: Jumping, spinning, rocking, etc.
What are some signs of dysregulation? What behaviors might we notice when participant is becoming dysregulated?
*
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About Me!
Additional Information that could be useful to staff
What do I like to be called, pronouns, things I really like, things I really don't like, my favorite snacks, which grade I'll be in this fall:
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Does participant have any motivators?
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Danvers Rec program you have in mind:
Any other information that could help support you in any aspect:
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Please upload a current picture!
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Acknowledgement
If you are 18 years or younger, please include parent/guardian signature.
Participant Name:
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Participant Signature:
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Parent/Guardian Signature:
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