Stafford County Parks and Recreation Inclusion Support Request

Stafford Parks and Recreation Inclusion Support Request Form
Name*

First NameLast Name
Parent Name (if <18)

First NameLast Name
Birthdate*

MonthDayYear
Date
Age*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Please describe the participants disability (be specific)*
Do you use a mobility device?*

YesNo
If yes, what kind? *
What percentage of the time do you use the mobility device?*
Height*
Weight*
Does the participant have any known allergies? If yes, please explain.*
Is there any other medical condition or concern that could impact participation? If yes, please explain.*
Are there any specific modifications or adaptations we can make that will assist us in serving you? If yes, please describe.*
Are you currently taking any medications? If yes, please list them.*
Can the participant independently communicate? If no, please explain.*
Does the participant utilize a personal aide? i.e. interpreter, one-on-one, tablet etc.? If yes, please explain.*
Behavioral Motivators:*
Behavioral Triggers:*
Behavioral Strategies or Suggestions:*
Have you participated in therapeutic recreation or adaptive sports before? If yes, where and when?*
What is the primary reason for joining this specific program? i.e. goals, motivations?*
Program(s) participant is registering for?*
What Parks and Recreation Division does your program(s) involve?*

Community Recreation (i.e. Summer Camp, Dance)GymnasticsSports
I affirm that the above is accureate and true. I understand inclusion services are designed to assist the participant in desired recreational pursuit and assure their specific accommodation needs are met. All participants are held to the same minimum conduct standards appropriate for each program.
I understand Stafford County Parks and Recreation staff do not provide personal care (including but not limited to: toileting, dressing and transportation outside of the program). However, we will gladly accommodate the participant’s personal care
aid/companion with our programs. I understand completion of this form is required. Information provided to Stafford County Parks and Recreation will be kept confidential. Information will only be shared with SCPRCF affiliated personnel when it is in the best interest of the participant and to support successful participation in a program.
Signature*

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Name*

First NameLast Name
Date*

MonthDayYear
Date
All support requests and registration forms are valid for 1 calendar year unless participant has experienced any medical
changes. This includes but is not limited to, a change in status or diagnosis, change in medication, undergone surgery or
changed assistive device.
Should be Empty:

Stafford Parks and Recreation Inclusion Support Request Form