Inclusive Recreation Programming Membership Application

Inclusive Recreation Programming

This survey is an application to be approved for the Inclusive Recreation Programming membership with The Recreation Department of The Corporation of The City of Windsor. An Inclusive Recreation Programming staff will be in contact to review your application. Completing this survey does not guarantee that the applicant will be approved for an Inclusive Recreation Programming membership.

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* 1. Applicant's Name

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* 2. Applicant's Age

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* 3. Parent/ Guardian Name

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* 4. Parent/ Guardian Relation

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* 5. Parent/ Guardian Phone Number

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* 6. Parent/ Guardian Email

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* 7. Has the applicant participated in recreation programming previously?

Yes

Additional Information (please specify)

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* 8. Does the applicant have any physical disabilities, assistive devices, and/or additional support needs?

Contacts

Eye Glasses

Hearing Aids

Ear Plugs

Tubes (Ears)

Crutches

Orthotics

Walker

Crutches

Walking Stick

N/A

Other (please specify below)

Other (please specify)

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* 9. Describe any behaviours or safety concerns we should be aware about.

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* 10. How does the applicant interact in social settings?

Is able to follow the typical group schedule and rules.

Is able to follow the typical group schedule and rules, may need breaks during the day.

Is not able to follow the typical group schedule and rules.

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* 11. What is the applicant's behaviour/ response to being told no or re-directed, new environment, change of routine, participating in an activity that is not preferred

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* 12. Applicant's Comfortability

	Never	Sometimes	Always	N/A
Comfortable in a crowded/ loud programming environment	Comfortable in a crowded/ loud programming environment Never	Comfortable in a crowded/ loud programming environment Sometimes	Comfortable in a crowded/ loud programming environment Always	Comfortable in a crowded/ loud programming environment N/A
Comfortable in a pool environment	Comfortable in a pool environment Never	Comfortable in a pool environment Sometimes	Comfortable in a pool environment Always	Comfortable in a pool environment N/A
Comfortable in an outdoor environment	Comfortable in an outdoor environment Never	Comfortable in an outdoor environment Sometimes	Comfortable in an outdoor environment Always	Comfortable in an outdoor environment N/A

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* 13. Does the applicant take medication?

Yes

If you selected "yes", please specify what medication they take.