Youth 2026 Summer Adaptive

Adaptive

Grow & Explore Summer 2026 Youth
Youth Age 6-8Youth Age 9-10Youth Age 11-12Teen 13-15Teen 16-17Adult 18-22
PERSONAL INFORMATION
Participant Name:*
DOB:*

MonthDayYear
Date
Age:*
Sex:*
T-Shirt Size*
Home address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name(s):*

First NameLast Name
Parent/Guardian Name(s):*

First NameLast Name
& Phone #:*
Format: (000) 000-0000.
Email address:*
example@example.com
Grade:*
School Name:*
Support Coordinator Name:*
Email:*
example@example.com
If you DO NOT wish to give photo/video permission, please initial here:
EMERGENCY CONTACTS
Name:*
First and Last Name
Relationship*
Phone #:*
Format: (000) 000-0000.
Phone #:
Format: (000) 000-0000.
Name:*
First and Last Name
Relationship*
Phone #:*
Format: (000) 000-0000.
Phone #:
Format: (000) 000-0000.
MEDICAL INFORMATION
Primary Diagnosis:*
Other/Secondary:
YESNO
If you answered YES, please list known allergies:*
Please describe procedure for care:*
YESNO
If YES, please list equipment:*
YESNO
YESNO
Last seizure date?:*
Please describe procedure to follow for care:*
NUTRITIONAL NEEDS
YESNO
If YES, please list:*
PERSONAL CARE NEEDS
NeverRarelyOccasionallyOftenRegularly
NeverRarelyOccasionallyOftenRegularly
NeverRarelyOccasionallyOftenRegularly
NeverRarelyOccasionallyOftenRegularly
NeverRarelyOccasionallyOftenRegularly
NeverRarelyOccasionallyOftenRegularly
NeverRarelyOccasionallyOftenRegularly
NeverRarelyOccasionallyOftenRegularly
NOTE: Participants must be physically independent to take care of bathroom needs. Staff are unable to assist participants with bathroom needs.
YESNO
YESNO
Please describe:*
YESNO
YESNO
If you answered YES, please describe:*
YESNO
If you answered YES, please describe:*
YESNO
If you answered YES, please describe:*
YESNO
If you answered YES, please describe:*
Sensory: What kind of sensory experience does participant avoid or seek?
SeeksAvoids
SeeksAvoids
SeeksAvoids
SeeksAvoids
SeeksAvoids
SeeksAvoids
YOUTH (6-12) ACTIVITY INTEREST
YESNO
If you answered NO, please describe:*
YESNO
If you answered NO, please describe:*
SportsCookingMusicLEGOSArtsVideo GamesScienceWater DaysAnimalsMoviesField TripsPool
Knowing your summer participant is important to our staff! Please list any additional likes and dislikes of activities, TV interests, music, etc:
Knowing your summer participant is important to our staff! Please list any additional likes and dislikes of activities, TV interests, music, etc.:
Likes*
Dislikes*
Please list any other information that would be important for our staff to know about your participant:*
PROGRAM ATTENDANCE
Part TimeFull Time
MondayTuesdayWednesdayThursdayFriday
Please list any known vacation dates when your participant will NOT be at program.*
Medication Policy and Procedures
Participant Name:*
My Participant WILL need medication administered during the City of Peoria, Summer Program.
Medication #1
Name of Medication:
Time to administer:
Dosage:
Additional instructions:
Medication #2
Name of Medication:
Time to administer:
Dosage:
Additional instructions:
Medication #3
Name of Medication:
Time to administer:
Dosage:
Additional instructions:
Parent/Guardian Name:*
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
If any changes in medication dosage or time given occur a new prescription bottle and label must be given to the Program Lead. All medication needs to be clearly labelled. Over the counter medication can only be given out with a doctors note. No participant is permitted to keep medication in their possession.
City of PeoriaProgram Consent Form
Participant Name:*
By signing below I hereby consent to allow the participant listed above to participate in the following activities while being involved in the DDD Programs with the City of Peoria.
Activity/Program Consent
Please note, LEGAL Guardian should initial next to the following below:
YESNO
Initials*

Clear
YESNO
Initials*

Clear
YESNO
Initials*

Clear
YESNO
Initials*

Clear
I/we hereby release and forever discharge Peoria Unified School District and the City of Peoria, an Arizona municipal corporation, its elected and appointed officials, directors, officers, boards, commissions, agents, representatives, servants, and employees, and any and all other persons, firms, or corporations who are or might be liable, from any and all claims of any kind or character which I/we have or may have against them due to my participation, or my child's participation, in a City of Peoria recreation program at a Peoria Unified School District facility. This waiver includes all damages, losses, costs, expenses, and injuries that allegedly occur during the course of this recreation program. In that regard, I/we covenant to indemnify, defend, and hold harmless to the fullest extent permitted by law the foregoing persons and entities from any loss or damages, including reasonable attorneys' fees and litigation expenses, which may be incurred by them in the event any such claims are asserted against them or any of them. I/we understand that medical claims are my/our responsibility. This waiver does not extend to any such claim or liability that is caused by the sole and exclusive intentional acts or gross negligence of Peoria Unified School District and/or the City of Peoria or its officers, employees, or agents. By signing, I authorize the City of Peoria to use and/or disclose certain protected health information (PHI) about me to any state licensing agency. I give my consent to the City to take photos/video of my child to be used by the City for program promotion.
Parent/Guardian Name:*
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
City of Peoria
Summer Program Attendance/Drop-off & Pick-up Form
Participant Name:*
MondayTuesdayWednesdayThursdayFriday
Please list any known vacation dates when your participant will NOT be at program.*
Drop-off/Pick-up Authorized Person #1
Name of authorized pickup/drop off:*
Phone number:*
Format: (000) 000-0000.
Relationship to the participant:*
Car make/model:*
Drop-off/Pick-up Authorized Person #2
Name of authorized pickup/drop off:*
Phone number:*
Format: (000) 000-0000.
Relationship to the participant:*
Car make/model:*
Drop-off/Pick-up Authorized Person #3
Name of authorized pickup/drop off:*
Phone number:*
Format: (000) 000-0000.
Relationship to the participant:*
Car make/model:*
Parent/Guardian Name:*
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Adaptive

PERSONAL INFORMATION

EMERGENCY CONTACTS

MEDICAL INFORMATION

NUTRITIONAL NEEDS

PERSONAL CARE NEEDS

Sensory: What kind of sensory experience does participant avoid or seek?

YOUTH (6-12) ACTIVITY INTEREST

Knowing your summer participant is important to our staff! Please list any additional likes and dislikes of activities, TV interests, music, etc.:

PROGRAM ATTENDANCE

Medication Policy and Procedures

Medication #1

Medication #2

Medication #3

City of PeoriaProgram Consent Form

Activity/Program Consent

City of Peoria

Summer Program Attendance/Drop-off & Pick-up Form

Drop-off/Pick-up Authorized Person #1

Drop-off/Pick-up Authorized Person #2

Drop-off/Pick-up Authorized Person #3