Inclusive Recreation Intake Form

INCLUSIVE RECREATION INTAKE FORM
Thank you for your participation in City of Federal Way Inclusive Recreation programs. Please fill out both sides of this form thoroughly. This will help us get to know your needs on an individual level. Please note that this form will expire every 3 years. If you have additional updates within this timeframe, please submit an updated form. If you need special accommodations in order to participate, please call us ten working days in advance of the activity start date, and we will

make every effort to accommodate reasonable requests. There may be situations in which a guardian or care provider will need to attend programs to assist.
Participant First & Last Name*
Participant Birthdate*

MonthDayYear
Date
Participants Gender*
Primary Phone*
Participant Cell Phone (if applicable)
Address*

Home address

Street Address Line 2

CityState / Province

Zip
Primary E-mail address*
example@example.com
Email Address Owner (Participant or Caretaker?)*
Race*
Languages spoken at home*
Is this individual their own Legal Guardian?*

YesNo
The Participant is Living:*

IndependentlyWith parents/ guardiansIn Group HomeWith Tenant SupportOther
GUARDIAN INFORMATION
Name of Legal Guardian/Parents*
Guardian Primary Phone*
Secondary Phone
Address (If different than above address)

Address (if different than above)

Street Address Line 2

CityState / Province

Zip
Guardian Email*
example@example.com
GROUP HOME INFORMATION (IF APPLICABLE)

Only fill this section out if Participant lives in a Group Home or Tenant Support
Name of Group Home/Tenant Support (If Applicable)
Name of Administer/Staff (If Applicable)
Home Phone
Secondary Phone
Please enter a valid phone number.
E-mail
example@example.com
EMERGENCY CONTACT
Additional Emergency Contact Name*
Relationship to Participant*
Emergency Contact Main Phone*
Emergency Contact Cell Phone
Participant's Physician
Physician Phone
PRIMARY CONTACT

Primary person to contact regarding program updates, emails, cancelations and transportation
Primary Contact Name*
Phone*
Email*
example@example.com
PAYMENT & REGISTRATION CONTACT

Primary person to contact regarding program registrations and payments
First & Last Name*
Phone*
Email *
example@example.com
TRANSPORTATION INFORMATION
How does this participant arrive and depart programs (please check all that apply)*

Metro Access BusCaregiver drop off/pick upPublic BusWalk/BikeDrive Self
If caregiver drop-off/ pick up, by whom?
Does this participant have permission to wait at the OPEN Community Center independently and unattended at the end of program to wait for their ride:*

YESNO
MEDICAL INFORMATION
Medical Information (Please check all that apply):*

ADDADHDAllergies (see below)Assists in toiletingAssists in feedingAsthmaAutismBehavioral disorderDevelopmental DisabilityDiabetesHearing ImpairmentHeart conditionHigh Blood pressureHistory of Seizures (see below)Intellectual DisabilityLearning DisabilityNon-verbalPhysical disabilitySpecial dietary needs (see below)Uses sign languageUses communication deviceVisual ImpairmentWanders easilyOther
Mobility Needs (Check all that apply):

Uses manual wheelchairUses power wheelchairUses assistive walking device (cane, walker, crutches)Balance difficultiesDifficulties climbing stairsDifficulties walking longer distances
Please List ALL Allergies (if applicable)
Please List ALL Dietary Needs (if applicable)
Seizures (if applicable): Please list date of last seizure, frequency, and attach seizure plan below.
Sensitivities: Please list any noises, activities, or situations that bother the Participant.
Do Program Staff have permission to apply sunscreen to Participant during programs?*

YESNO
Medications: Please list ALL Medications or attach below
Will participant be taking medication during activities? If so, how frequently?*
MEDICATION POLICY

Staff are unable to administer any type of medication at our programs. It is up to the individual, guardian, or caregiver to administer these before or during our programs (this includes over the counter medications
Additional Information: Is there anything else that would be helpful for us to know?
File Upload. Please use this portal to upload any medical documents, seizure plans, or additional files that may help us better understand the needs of the Participant.

Cancelof
PROGRAM AUTHORIZATION
I Authorize The Participant to attend the following types of programs:*

In City facilities which remain on-siteOutside City facilities (day trips)Overnight Programs
PHOTO RELEASE. I authorize full permission of this participant to be photographed (still or video) within the City of Federal Way programs for any purpose*

YESNO
Please type your initials*
I authorize full permission of this participant to be photographed (still or video) within the City of Federal Way programs for any purpose. Initials: Date

MonthDayYear
Date
POLICIES & AGREEMENT

Providing the above information will help us to ensure that participant has a positive experience in the Federal Way Inclusion programs. Efforts will be made to provide reasonable accommodation in accordance with the Americans with Disabilities Act.
FEDERAL WAY INCLUSION POLICY
The City of Federal Way Parks Department is committed to serving the needs of everyone in the community through inclusive programming, providing an atmosphere in which persons with and without disabilities can interact, play, and socialize with their peers in an all-inclusive, supportive environment. The Americans with Disabilities Act (ADA) prohibits discrimination in public programs or services based on disability. The City of Federal Way strives to create an accessible environment in our general recreation programs for our diverse population. People of all abilities are invited to consider registering for any recreation program Federal Way Parks has to offer provided minimum eligibility requirements are met. If you have any questions about accessibility in any of our programs contact Sabrina Bates at Sabrina.Bates@cityoffederalway.com or (253) 835-6927.

See full policy here: itallhappenshere.org/inclusive-recreation-policy
LATE PICK UP POLICY
LATE PICK UP POLICY: We ask for your cooperation in departing from activities in a timely manner. It is important to understand that you are responsible for arranging departure within 30 minutes of the program end time, regardless of what transportation arrangements are made.

After the 30 minute pick-up time has passed, A LATE CHARGE OF $5.00 PER QUARTER HOUR will be assessed and must be paid at Federal Way Community Center by phone or walk-in before the next program date. Habitual late arrivals for pick up may lead to program dismissal.
AGREEMENT
CONSENT TO RELEASE/ OBTAIN INFORMATION: I give the City of Federal Way Recreation staff permission to contact other city staff members and emergency responders to obtain and/or release personal and medical information, to be used for the sole purpose of providing excellent, effective, and safe program services. This information will remain confidential.

RELEASE OF LIABILITY: The undersigned agrees to save the City of Federal Way harmless for all liability, accident, injury or loss of property resulting from the use of city facilities, travel to said facilities, or participation in programs administered by the parks, Recreation and Cultural Services staff. In case of injury I do hereby waive all claims or legal actions, financial or otherwise, against the City of Federal Way, its organizers, sponsors, supervisors, or any volunteer connected with the program unless injury is caused by sole negligence of the City of Federal Way. In absence of signature, payment fees and participation in the program shall constitute acceptance of the conditions set forth for any purpose.
Name of Participant*
Signature of Participant (if 18 years or older)*

Clear
Signature of Legal Guardian (required if applicable for individual of any age)

Clear
Date

MonthDayYear
Date
DDA BILLING

For use by participants using DDA funding only.
DDA Case Manager
Case Manager Email
example@example.com
I authorize The City of Federal Way Inclusion Program to bill DDA Respite Funds for registered programs, and I understand I am responsible for any costs that are not covered by the Washington Developmental Disabilities Association per my Service Plan.

Clear
APPAREL SIZING

For participant’s participating in Special Olympics only. Please list your current sizes for jerseys/uniforms. All apparel is unisex sizing.
Tops / Shirts
Bottoms / Pants
Should be Empty:

INCLUSIVE RECREATION INTAKE FORM

GUARDIAN INFORMATION

GROUP HOME INFORMATION (IF APPLICABLE)

EMERGENCY CONTACT

PRIMARY CONTACT

PAYMENT & REGISTRATION CONTACT

TRANSPORTATION INFORMATION

MEDICAL INFORMATION

MEDICATION POLICY

PROGRAM AUTHORIZATION

POLICIES & AGREEMENT

FEDERAL WAY INCLUSION POLICY

LATE PICK UP POLICY

AGREEMENT

DDA BILLING

APPAREL SIZING