YMCA Adaptive Program Request

  • YMCA ADAPTIVE PROGRAMS

    REQUEST FOR SUPPORT

  • We are excited that you have selected the YMCA of San Diego County for your Child and Youth Development (CYD) needs! The YMCA is committed to providing a safe and positive experience where children can meaningfully participate in our programs.

    Inclusion is an interactive process between the family and the branch that sets into place a process to create a success plan for our participants. The following is a YMCA of San Diego County information form that will help initiate the process and will be shared with leadership from the interested programs. Staff will contact you to discuss the next steps and provide registration information.

  • APPLICANT INFORMATION

  • Parent/Guardian Date of Birth
     - -
  • Format: (000) 000-0000.

  • PARTICIPANT INFORMATION

  • Date of Birth*
     - -
  • GENDER*

  • FAVORITES & INTERESTS

  • SUPPORT INFORMATION

  • MEDICAL & PHYSICAL INFORMATION

  • BEHAVIOR INFORMATION

  • Potential Behaviors

  • COMMUNICATION INFORMATION

    • Expressive (Talking) 
    • COMMUNICATION
    • Sign Language
    • Augmentative Devices
    • Receptive (Understanding) 
    • Follow simple directions
    • User visual schedule

  • ADDITIONAL INFORMATION

    • I understand and agree to the following:
    • This form is not a promise or a guarantee of your child’s placement in any YMCA program.
    • The information provided during this process will be shared with staff working with my child and they are authorized to discuss for the purpose of meeting my child’s needs.
    • This program is not designed to be therapeutic or provide one-on-one care.
    • The YMCA of San Diego County operates within the provisions of the Americans with Disabilities Act which provides protection to individuals with disabilities, as well as to providers of care for these individuals.
    • It is YMCA policy to remove any child from the program determined to pose a threat to themselves, other children or staff, or the overall program environment of health and safety, including children with disabilities and special needs.
    • Although every effort is made to provide reasonable accommodations, there may be instances where a child’s needs may exceed the parameters of the scope of our program.

    The information I have provided on this form is complete and accurate and, to the best of my knowledge, contains all the information that the YMCA needs to have to help meet my child’s needs and facilitate my child’s success in this program.

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