Participant Intake Form

** All responses are for informational purposes only to help meet your child(ren)'s individual needs. Answers will not disqualify participants from enrolling and will be kept confidential by City of Steamboat Springs Recreation staff. Filling out this form is voluntary; however, additional information will help us to better serve and support your child(ren **

Child 1 Name*

First, Last name

Has your child participated in any City of Steamboat Springs Recreation Programs in the past?*

YesNo

If yes which ones

What hobbies or activities does your child enjoy*

What motivates your child to follow instructions and complete a task*

Any areas of concern that staff should know about specific behavior group interactions conflicts etc

What strategies work well for addressing your childs challenging behavior

Any relevant medical history or diagnoses that staff should know about

Any relevant family information or history that could explain a childs behavior

Any other information that could be relevant to your childs participation in our Recreation Programs

Participant Intake Form, page 2

Child 2 Name

Has your child participated in any City of Steamboat Springs Recreation Programs in the past?

YesNo

If yes which ones

What hobbies or activities does your child enjoy

What motivates your child to follow instructions and complete a task

Any areas of concern that staff should know about specific behavior group interactions conflicts etc

What strategies work well for addressing your childs challenging behavior

Any relevant medical history or diagnoses that staff should know about?

Any relevant family information or history that could explain a childs behavior

Any other information that could be relevant to your childs participation in our Recreation Programs

Participant Intake Form, page 3

Child 3 Name

Has your child participated in any City of Steamboat Springs Recreation Programs in the past?

YesNo

If yes which ones

What hobbies or activities does your child enjoy

What motivates your child to follow instructions and complete a task

Any areas of concern that staff should know about specific behavior group interactions conflicts etc

What strategies work well for addressing your childs challenging behavior

Any relevant medical history or diagnoses that staff should know about

Any relevant family information or history that could explain a childs behavior

Any other information that could be relevant to your childs participation in our Recreation Programs