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2. 
4. Accommodations Request Form
8. Participant Information

   Please allow Community Services staff at least three weeks before the program start date to ensure adequate time to prepare accommodations for this participant.

10. First Name*
11. Last Name*
13. Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Email Address*
22. Participant Date of Birth
23. Month*
    -- Select One --01 - January02 - February03 - March04 - April05 - May06 - June07 - July08 - August09 - September10 - October11 - November12 - December
24. Date*
    -- Select One --12345678910111213141516171819202122232425262728293031
25. Year*
27. Please indicate*

    1. I am the person listed above requesting an accommodation that will allow me to participate in a program, activity, or service.
    2. I am requesting an accommodation on behalf of the participant listed above.
29. Please state your name and relationship to the participant who needs an accommodation. Answer N/A if you are the participant.*
33. Program Information*

    Please select program

    1. Swim Lessons
    2. Summertime Fun Club/Summer Teen Pack
    3. Aquatics
    4. Classes
    5. Other summer camps
    6. Adult Sports
35. Program/Activity/Class*
37. Program Location*
39. Program Dates*
    Program Dates Start Date

    —

    Program Dates End Date
40. Start/End Time of Program*
    Start/End Time of Program Start Time

    —

    Start/End Time of Program End Time
42. Select accommodation request needed:*

    1. Needs assistance following directions
    2. Needs visual aids
    3. Needs more time transitioning
    4. Needs motivation for less favorable activities
    5. Needs personal aide present
    6. Needs staff awareness of accommodation
    7. Behavior Support Plan
    8. Other (see below)
44. Additional Accommodation Request Information*

    Please provide details of the accommodation for your request and include any other requests not mentioned above.

48. Goal(s) for Participation*

    Please select one or two goals you hope the participant achieves in the program.

    1. Participation in activity
    2. Socialization with participants
    3. Improvement of activity skills
    4. Improvement of socialization skills
    5. Physical fitness

50. Medical Information

52. Primary Disability
54. Assisted Devices Used
56. Medication
58. Please add other pertinent medical information staff should be aware of

    Example(s): allergies, seizures

60. Behavior and Communication
62. Check all that apply*

    1. Comprehends and communicates verbally
    2. Has limited verbal communication skills
    3. Initiates conversation with others
    4. Maintains appropriate personal space for self and others
    5. Easily transitions between activities
    6. Runs away from supervision/activities

    1. One-on-one assistance supervision is needed
    2. Minimal assistance/supervision needed
    3. Self-regulates aggression/frustration
    4. Aggressive towards self
    5. Aggressive toward others
64. Type and Frequency of Aggression*

    Please describe type and frequency if you selected: "Aggressive towards self" or "Aggressive toward others". 

    If you did not select these options, please put NA.

66. When specific behaviors occur, how can staff help the participant?*

    Example 1: If the participant attempts to leave or avoid a less preferred activity, staff can redirect their attention by engaging in a preferred topic, such as talking about Spiderman, to help them rejoin the group.

    Example 2: If the participant appears overstimulated, staff should offer support by providing access to a quiet space or suggesting a calming activity, such as taking a walk.

68. Please use the space below to disclose any triggers or signs staff should be aware of before a behavior or situation occurs.*
72. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
74. Electronic Signature
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field