Inclusion Request

Inclusion Request

Complete this form to request inclusion support services in a Burlington Parks and Recreation (MA) program.
**NOTE: Completing the inclusion request form does NOT count as registering for the program. Registration must be completed FIRST at www.burlingtonrecreation.org**
- What type of inclusion model does Burlington Parks & Recreation follow?
  - Burlington Parks and Recreation utilizes a group inclusion model and 1:1 support is granted only on an as-needed basis, pending assessment by the therapeutic recreation specialist and pending staff availability.
  - It will take a minimum of two weeks for inclusion services to begin.
- What does Inclusion Support look like?
  - Inclusion support is a process designed to increase independence within programs over time.
  - Inclusion support will look different for each individual participant!
  - The Therapeutic Recreation Specialist will utilize a comprehensive inclusion support assessment to determine which support strategies may work best for that individual participant.
  - Examples of these strategies may include
    
    Previewing an activity prior to attending program
    
    Developing support strategy tools (schedules, visual supports, social/emotional supports, etc).
    
    Working with an instructor to coordinate accommodations.
    
    Increasing staff ratios in a program pending staff availability.
Inclusion Request Information
If you are completing this request on behalf of a participant (i.e you are their parent/guardian) complete the information below.

If you are a participant and you are your own guardian please skip over parent/guardian questions.
Name of Participant*

First NameLast Name
Name of Parent/Guardian

First NameLast Name
Phone Number of person completing this form
Please enter a valid phone number.
Email of person completing this form
example@example.com
What is your preferred contact method?

Phone CallEmail
Program *
Name of program support is requested within
Brief description of requested supports*
Signature *

Powered by Jotform SignClear
I understand by signing this request that the Therapeutic Recreation Specialist will be contacting me to discuss inclusion support within programs. I understand that it will take a minimum of two weeks for inclusion services to begin pending staff availability.
Should be Empty:

Inclusion Request

Inclusion Request Information