City of Waterloo Inclusion Membership Application

City of Waterloo Inclusion Membership Application
Some participants may need extra support to be program ready. This could include having an Inclusion Support Worker coordinated through City of Waterloo Inclusion Services.

Program ready means:
1. Take instructions from a staff person and participate in programmed activity.
2. Use the bathroom without a known guardian around, without regular accidents.
3. Feels comfortable interacting in a group environment, to the best of their ability.
4. Can participate in a way that is safe for themselves and others.
If you answered ‘no’ to any of the above, please complete the application for Inclusion Services Membership.

Why we are asking for your information:

The personal information and personal health information we collect in this form helps us provide services that are tailored to each person’s unique needs. This information is protected under the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). It may be shared with volunteers, inclusion staff, on-site staff, or program coordinators on an as-needed basis. Complete details can be found under 'Terms and Conditions' at the end of this form.
Applicant information

This section collects details about the person seeking inclusion support services.
Are you completing this application for yourself?

YesNo
Applicant's full name*
Applicant's first and last name
Applicant's preferred name
If different than first name above.
Applicant's date of birth*

MonthDayYear
Applicant's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's email
If applicable. If the applicant does not have their own email address, you may leave this blank. A copy of the completed form will be sent to this email, upon submission.
Applicant's primary phone number
If applicable. If the applicant does not have their own phone number, you may leave this blank.
Person completing the application

This section collects information about the person completing this form, on behalf of the applicant.
Full name of the person completing this form*
Your first and last name.
Are you a parent of the applicant?

YesNo
What is your relationship to the applicant?*
How are you related to the applicant? For example, mother, father, guardian, etc.
Your email*
This is the email we will use to contact you if we have any questions about this form. A copy of the completed form will also be sent to this email, upon submission.
Your phone number*
This is the phone number we will use to reach you if we need more information about this form.
Parent or caregiver information

This section collects the contact information for the applicant's parent(s) or caregiver(s), if applicable.
Primary caregiver's full name:*
Relationship to applicant*
How is this person related to the person signing up for the program? For example, parent, guardian, etc.
Primary caregiver's email*
Primary caregiver's phone number*
Please enter a valid phone number.
Additional caregiver's full name
Caregiver's first and last name
Relationship to applicant
How is this person related to the person signing up for the program? For example, parent, guardian, etc.
Additional caregiver's email
Additional caregiver's phone number
Please enter a valid phone number.
Emergency contact information

This section collects the contact information of someone who can be reached in case of an emergency during the program. This person should be different from the primary caregiver.
Emergency contact's full name
First and last name.
Relationship to applicant
How is this person related to the person signing up for the program? For example, grandparent, friend, etc.
Emergency contact's primary phone number
The main phone number where the emergency contact can be reached.
Emergency contact's alternate phone number
If possible, provide a second phone number in case the emergency contact cannot be reached at their primary number.

Medical information
Are there any activities the applicant cannot participate in due to medical reasons?*

YesNo
List the activities the applicant cannot participate in.*
Does the applicant take any medications?*

YesNo
List the medications.*
Does the applicant have any allergies?*

YesNo
List all allergies and associated symptoms / reactions.*
Has the applicant ever had a seizure?*

YesNo
Date of the last seizure*

MonthDayYear
Duration of the last seizure*
Type of last seizure*
Are seizures a common occurrence?*
Are there seizure warning signs to look for?*
What is the preferred action if the applicant experiences a seizure in program?*

Terms and Conditions
Program Readiness

We are committed to giving everyone a safe, active, and fun program. We play fair and show respect for ourselves and for others. Our rules of program behaviour include:
1. Keep your hands and feet to yourself.
2. Speak nicely to each other.
3. Touch only what belongs to you.
4. Stay within the activity area.
5. Listen to your leaders.
Membership can look different for each individual depending on their unique needs. One service may be an Inclusion Support Worker. Inclusion Support Workers are typically post-secondary students who receive training in personal care, calming techniques, lifts and transfers, and other behaviour management strategies.

Staff will use the least directive to most directive approaches. If there are immediate concerns for the safety of the participant or others, we may need to intervene by holding the participant. Physical intervention is always used as a last measure to ensure participant safety.

If a participant is not able to be program ready with the support of an Inclusion Support Worker, they may require shortened programming hours, early pick-ups or as a last resort, removal from program.

Personal information

Personal information is collected under the authority of s. 28(2) of the Municipal Freedom of Information and Protection of Privacy Act in accordance with s. 11(1) of the Municipal Act.

The personal information collected herein and including any personal health information and/or emergency contact information will be used only for purposes relating to the programs and will be protected in accordance with the requirements stipulated in the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56 (the “MFIPPA”).

Personal information collected on this form (and in subsequent interview, phone conversation and email correspondence) will be used to evaluate any request for support. The information disclosed will be shared in part or in full with the volunteer, inclusion service staff, on-site staff and program coordinators only to the extent of ensuring a successful accommodation placement for the participant.

Inquiries about the collection, use or disclosure of your personal information should be directed to the Inclusion Services Coordinator at 519-886-2310 x 27249 or by email at inclusion@waterloo.ca.

Indemnity

I agree to indemnify and hold harmless the Corporation of the City of Waterloo (the “City”) and its elected officials, officers, employees, agents and volunteers, and the affiliated Neighbourhood Association of the City at which the Inclusion Services are provided and its officers, employees, agents and volunteers, from any and all claims, demands, actions, losses, causes of action, proceedings, suits, damages, expenses or liability of any kind, including reasonable legal fees and expenses of litigation, brought by any person, whether in respect of death, damage, harm or injury to person or damage to property, arising from any occurrence occasioned, whether in whole or in part, whether directly or indirectly, by an act, omission or negligence of the City, or by an act, omission or negligence of myself.
I hereby acknowledge that I read the foregoing carefully and understand and agree to its content. I have completed this form in full and have read and understood the terms and conditions.*

Yes
Signature or mark

Please sign, make a mark, or type your name to confirm the information provided in this form is correct.
Signature or mark

Clear
Typed signature*
Clicking the 'Submit' button below will send your form to the Inclusion Services team. A copy of your submitted form will be sent to the email addresses of the applicant and the person completing the form. If you don’t receive the email in a few minutes, please check your spam or junk folder. If you still haven’t received it after two hours, your form has not been submitted. Please fill out the form again.
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