Inclusion Observation Request Form

Submitted by*

E-mail Address (for confirmation)*

Date Submitted*

Season*

Year

Participant's Name*

Date Of Birth*

Male
Female

Parent/Guardian Name*

Parent/Guardian Email*

Parent/Guardian Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Park District*

Supervisor*

Supervisor Email*

Program Title*

Program Number

Program Location (include Rm #)

Day of Week*

Time*

Date Program Begins*

Date Program Ends*

Does not meet on

Name of Instructor

Please indicate below, which type of assistance is requested

Classroom
Individual
Training
Other

Additional Comments (If requesting an individual observation please indicate any communication with the family)*

Is the participant registered for a second program?*

Supervisor program 2

Supervisor 2 Email

Program Title 2

Program Number 2

Program Location 2 (include Rm #)

Day of Week 2

Time 2

Date Program Begins 2

Date Program Ends 2

Does not meet on 2

Minimum Age 2

Maximum Age 2

Staff/Participant Ratio 2

Name of Instructor 2

Class Prerequisites? 2

Equipment/Supplies Needed 2

Please indicate below, which type of assistance is requested 2

Training
Observation
Additional Staff
Modified Equipment
Other

Additional Comments 2

Is the participant registered for a third program?*

Supervisor program 3

Supervisor 3 Email

Program Title 3

Program Number 3

Program Location 3 (include Rm #)

Day of Week 3

Time 3

Date Program Begins 3

Date Program Ends 3

Does not meet on 3

Minimum Age 3

Maximum Age 3

Staff/Participant Ratio 3

Name of Instructor 3

Class Prerequisites? 3

Equipment/Supplies Needed 3

Please indicate below, which type of assistance is requested 3

Training
Observation
Additional Staff
Modified Equipment
Other

Additional Comments 3

Is the participant registered for a fourth program?*

Supervisor program 4

Supervisor 4 Email

Program Title 4

Program Number 4

Program Location 4 (include Rm #)

Day of Week 4

Time 4

Date Program Begins 4

Date Program Ends 4

Does not meet on 4

Minimum Age 4

Maximum Age 4

Staff/Participant Ratio 4

Name of Instructor 4

Class Prerequisites? 4

Equipment/Supplies Needed 4

Please indicate below, which type of assistance is requested 4

Training
Observation
Additional Staff
Modified Equipment
Other

Additional Comments 4

Are Parents Aware of WDSRA Services?

Yes
No