2025 Inclusion Support Service Request

Participant Name

Date of Birth*

Age*

Address Line 1*

Address Line 2

City*

State*

Select

Parent/Guardian Name*

Parent/Guardian Email*

Parent/Guardian Phone*

Phone

Parent/Guardian Relationship to Camper*

Which weeks are the participant attending?*

Select

Type of Accommodation *

Assistive Equipment

Sign Language Interpreter

Additional Personal Assistance

Other

Does the camper walk independently?*

Select

Does the camper use any medications?*

If yes, please identify the type, dosage, and time of all medications the camper is currently taking.

Yes

No

Does the camper have any allergies?*

Select

Eating/Drinking Skills Assessment*

Please select each statement that applies to the camper. Use the comment section to identify additional needs.

Eating Drinking Additional Needs

Bathroom Skills Assessment*

Please select each statement that applies to the camper. Use the comment section to identify additional needs.

Bathroom Additional Needs

Communication Skills Assessment*

Please select each statement that applies to the camper. Use the comment section to identify additional needs.

Unable to communicate needs

Communicates with gestures, signs or non-verbal actions

Uses 1- or 2-word statements

Uses partial or complete spoken sentences

Communicates in writing

Communicates using basic sign Language

Independent

Uses a communication device to communicate

Communication Additional Needs

Receptive Language Skills Assessment*

Please select each statement that applies to the camper. Use the comment section to identify additional needs.

Recognizes own name when called

Responds to 2- or 3-step directions

Responds when spoken to

Responds to directions when in a small group

Responds appropriately to 1-step directions

Responds in a one-on-one direction

Responds appropriately to directions when in a large group

Receptive Language Additional Needs

Motor Coordination Skills Assessment*

Please select each statement that applies to the camper. Use the comment section to identify additional needs.

Able to catch a ball rolled

Able to kick a rolling ball

Able to catch a ball bounced

Able to grasp small objects

Able to catch a ball tossed from a short distance

Able to throw or roll a ball

Able to grip/grasp larger objects (tennis ball, racquet, etc.)

Able to kick a stationary ball

Motor Coordination Additional Needs

Social/Behavioral Skills Assessment*

Please select each statement that applies to the camper. Use the comment section to identify additional needs.

Will play/interact cooperatively with others

Shows interest in others

Will sit quietly to watch a program

Can identify personal belongings

Will play/interact cooperatively within a group

Needs additional reminders

Seeks Attention

Is aware of safety concerns when out in the community (traffic, staying with a group, etc.)

Social/Behavioral Additional Needs

Sensory Input Skills Assessment*

Please select each statement that applies to the camper. Use the comment section to identify additional needs.

Is sensitive to increased sensory input

Will display signs of discomfort

Is sensory seeking

Sensory Input Additional Needs

Behavior Management Techniques Used *

Yes

No

Independent Swimming*

Select

Please list any activities, games, hobbies, etc. that your camper enjoys, is motivated by, or has expressed interest in.

Care Team Contact*

Yes

No

Accommodation Requests*

By checking this box, I acknowledge that I have read and understand that one-on-one staffing is not provided, however, campers may bring their own support person, who must pass a criminal background check.

Accommodation requests are not required to participate in camp programs, however, all campers are required to meet the minimum participation guidelines and desired behavior expectations of the camp.

Completing an accommodation request does not guarantee services will be available.

Release of Information*

By checking this box, I, hereby give my permission for Columbus Recreation and Parks Inclusion Support staff to exchange and release educational, behavioral, and/or medical information to Recreation and Parks staff and the Care team specified above for the sole purpose of coordinating special accommodations to develop and implement the inclusion support plan for my child. No further information will be given to anyone without my prior written consent. All information will be used to plan appropriate activities for my child.

Signature*

I acknowledge that by typing my name in the below block, that this serves as a digital signature.

Send me a copy of my responses