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Assistance Request

Assistance is provided for participants upon request.

Blue Valley Rec prohibits the discrimination on the basis of race, color, national origin, sex, gender, age, religion, genetic information, pregnancy status, disability, sexual orientation, veteran status, and any other status protected by law in employment and its programs, activities, and services. BVRC complies with the Americans with Disabilities Act (ADA), under which qualified individuals with a disability may be entitled to reasonable accommodations in programs, activities, and services of and in employment with BVRC.
1.Email Address(Required.)
2.Your First, Last Name(Required.)
3.Your Contact Number(Required.)
4.Name of Participant to Receive Assistance(Required.)
5.Type of assistance requested(Required.)
6.BVRC Program/Activity Name(Required.)
7.Reason(s) for Assistance (please be specific so we can better understand how to help)(Required.)
8.Start date of Program/Class/Activity(Required.)
Date / Time
Time
:
9.How will the Inclusion Helper assist the participant during program/class/activity? (check all that apply)(Required.)
10.Are you or a family member also willing/able to provide assistance during the program/class/activty?(Required.)