WDSRA  •  116 N. Schmale Road  •  Carol Stream, IL 60188  •  (630) 681-0962   •  www.WDSRA.com
Western DuPage Special Recreation Association

Inclusion Notification Form

Questions regarding this form should be directed to Tammy Kerrins at 630-681-0962
or e-mail tammyk@wdsra.com.

Inclusion Request

Submitted by:         E-mail Address (for confirmation):

Park Dist Staff     or Parent/Guardian

Date Submitted:                  Season:   Year:


Participant's Name:         Date of Birth:    Male Female

Parent's Name:    Phone Number:    Parent email:

Address:        City:               Zip:


Park District:              Supervisor:

Program Title:             Program Number:

Program Location (include Rm #):

Day of Week:                Time:

Date Program Begins:     Date Program Ends:     Does not meet on:

Minimum Age:            Maximum Age:           Staff/Participant Ratio:

Name of Instructor:       Class Prerequisites?

Equipment/Supplies Needed:


Please indicate below, which type of assistance is requested:

Training Observation Additional Staff Modified Equipment Other


Additional Comments:

Are Parents Aware of WDSRA Services?

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