Camper Inclusive Services Request

Camper Inclusive Services Request

This form is intended to assist in identifying reasonable accommodations which may be beneficial for successful participation. Please complete as thoroughly as possible. Thank you!
Program Ready:
In order to support the success and safety of individuals registered and participating in recreation programs, it is important that participants are indeed “program ready.” To assist in determining if a person is “program ready,” the following criteria have been developed:
• Participant is able to participate independently or with reasonable accommodations.
• Participant is age appropriate.
• Participants may be aged up or down by one grade level in some situations.
• Participant is able to take direction and instruction from a staff person.
• Participant is comfortable with, and able to interact in, a group environment.
• Participant interacts and participates in a manner that is physically and emotionally safe for themselves and others.
• Participant is able to participate in self-care (toileting, feeding etc.) independently or with minimal verbal prompting.
Camper Name*

First NameLast Name
What program is the participant registering for?*
Date of birth*

MonthDayYear
Grade *
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Parent/Guardian*

First NameLast Name
What recreation interests does the camper have?*
What Bloomington Parks and Recreation programs has the camper previously participated in (if any)?*
Social Skills (Please select all that apply*

Shows interest in othersWill play/interact cooperatively with othersIs tolerant of others, not easily agitated or annoyedListens well and follow directionIs aware of safety concerns (traffic, staying with a group, hot stoves, etc.)Will sit quietly to watch a show, movie, etc.Can identify and take responsibility for personal belongings
Social skills comments/Areas of difficulty*
Please list any diagnoses*
Does the camper have seizures*
If yes, please indicate type of seizure and describe
Date of Most recent seizure
Is there a known trigger of seizures?
Please list any medications, their purpose and any side effects/contraindications.*
Please list any allergies, activity restrictions, special diets or other medical concerns.*
How does the camper communicate?*

SpeechRead LipsSign LanguageCommunication BoardTablet or other computerized DeviceOther
How can staff assist the camper in communicating needs?*
Does the camper eat and drink independently?*
If no, what type of assistance or adaptive equipment is needed
Does the participant walk independently?*
If no, identify any mobility devices used or assistance needed
Restroom Skills*

Wears Attends/Depend/DiaperIndicates need to use toiletUses toilet with physical assistanceUses toilet independentlyWashes hands independentlyOther
Do you feel the camper requires one to one supervision? (Level of supervision will ultimately be determined by the Inclusive Recreation Coordinator)*
How can Bloomington Parks and Recreation best accommodate the camper?*
Additional Comments or anything else you would like us to know about the camper.
To assist us in meeting needs, we require that registration for each program and reasonable accommodation requests be made at least two weeks prior to the program registration deadline. In some cases reasonable accommodations may take longer. This assessment expires one year from date of the assessment or in the event of significant change. Termination of inclusive recreation services must be completed through the Inclusive Recreation Coordinator. At no time may a participant or parent/guardian terminate inclusive recreation services without consulting the Inclusive Recreation Coordinator.
The information provided is to the best of my knowledge I agree and sign voluntarily by typing my name below*
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