Parks & Recreation Accommodation Request Form

If you are requesting any type of modification for the participant, you must submit a completed Inclusion Request form

at least 14 business days prior to the start of the program. Once a request is received, you will be contacted within 5

business days to schedule an assessment meeting to further discuss the needs of the participant

PARTICIPANT INFORMATION

Participant Name:*

Date of Birth:*

Program You Are Requesting Modifications For:*

Location of Program:*

Date of Program:*

Have you Previously Participated in a Program?*

Select

Nature of Limitations:*

Appropriate examples include unable to walk long distances, unable to see far away,

unable to hear certain sounds, etc.

Describe Requested Modification/ Accommodation:*

Provide any supporting documentation necessary to assist in processing the request. Attach additional pages if needed below.

File Upload

Drag and drop files here or

Name of Parent/Guardian(s):*

Phone Number:*

Phone

Email Address:*

Address:*

City:*

State:*

Zip Code:*

Signature*

By checking this box I am confirming all information to be accurate and true.

Send me a copy of my responses