• Inclusion Intake Form

  • The City of Guelph operates with an inclusive philosophy. By filling out this form, you are helping us get to know the participant’s unique capabilities, and how best to support them in programming.

    Please note, filling out this form does not confirm your inclusion support request for City of Guelph programs. To request inclusion support within a camp or program, you must:

    • First register for your program or camp of choice
    • Then register for Inclusion Seasonal Program Support or Inclusion Camp Support.

    Registrations can be made online at recenroll.ca or over the phone/in person. More information on registering for programs.

    Inclusion support can be provided in many ways, such as program modifications made by instructors, or by additional staff support in programs. In recognition of everyone’s unique assets and needs, a dedicated 1:1 support worker is not the guaranteed level of support you may receive. Support provided is at the discretion of the City and will be based on the needs of the participant and the resources available.

    Personal information collected on this form will be used to evaluate requests for support. The information disclosed will be shared in part or in full with the Inclusion Services team, on-site staff, and Program Coordinators only to the extent of ensuring a successful and safe experience.

    If you have any questions about inclusion supports, contact the City of Guelph Inclusion Coordinator at 519-822-1260 extension 2701 or inclusive.recreation@guelph.ca.

  • Date of birth*
     - -
  • Relationship to participant*
  • Has the participant received support from inclusion services before?*

  • Section 1: Strengths and interests

  • Please identify participant's interests (check all that apply)*
  • Please identify participant's strengths (check all that apply)*

  • Section 2: Medical information

  • Please indicate if the participant has a medical diagnosis (check all that apply)*
  • Does the participant have any allergies? (check all that apply)*
  • Does the participant carry an EpiPen?*
  • Does the participant take any medications?*
  • Does the participant have asthma?*
  • Does the participant carry a puffer?*
  • Has the participant had any seizures?*
  • Are there any activities the participant cannot participate in due to medical reasons?*

  • Section 3: Physical skills and activities of daily living

  • Does the participant use any equipment to participate in activities? (Check all that apply)*
  • Does the participant wear diapers?*
  • Does the participant wear pull ups?*
  • Does the participant have bladder control?*
  • Does the participant have bowel control?*
  • Does the participant require assistance with toileting?*
  • Rows
  • Does the participant have hearing difficulty?*
  • Does the participant have vision difficulty?*
  • Rows
  • Does the participant require assistance with eating or feeding?*
  • What is the participant's swimming level?*
  • Indicate the participant's swimming preferences and needs. (check all that apply)*
  • How does the participant enter/exit the pool?*
  • Are there challenges with the participant exiting the pool?*
  • Does the participant have any travel considerations when participating in an outing (accessible transit, seating preferences, adapted seat belt)*

  • Section 4: School and support needs

  • Does the participant attend school or daycare?*
  • Please indicate the participant's current classroom setting.
  • How long does the participant attend school?
  • Does the participant have a school safety plan?
  • What type of support does the participant receive at school (check all that apply)
  • Has the participant been in recreation programs before?*
  • What level of support has the participant received in the past? (check all that apply)
  • Would the participant benefit more from a male or female support worker?*

  • Section 5: Communication and social skills

  • Which method(s) of communication does the participant use (check all that apply)*
  • Rows

  • Section 6: Sensory and behaviour information

  • Are any of the following likely to trigger an emotional outburst. (check all that apply)*
  • Does the participant have any strong fears?*
  • Does the participant struggle with recognizing the danger of any of the following? (Check all that apply)*
  • What strategies and techniques do you find useful in managing the participant's behaviour? (Check all that apply)*

  • Has the participant exhibited any of the following behaviours in the past 6 months?

  • Anxiety*
  • How often?
  • Biting*
  • How often?
  • Verbal aggression toward others*
  • How often?
  • Physical aggression toward others*
  • How often?
  • Hitting*
  • How often?
  • Wandering*
  • How often?
  • Kicking*
  • How often?
  • Pinching*
  • How often?
  • Pulling hair*
  • How often?
  • Spitting*
  • How often?
  • Refusal to participate*
  • How often?
  • Screaming*
  • How often?
  • Self-injurious behaviour*
  • How often?
  • Is participant a flight risk?*
  • How often?

  • Consent and acknowledgement

  • Date submitted
     - -

  • Collection of personal information

    Personal information, as defined by the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) is collected under the authority of the Municipal Act, 2001, and in accordance with the provisions of MFIPPA (Municipal Freedom of Information and Protection of Privacy Act).

    If you have any questions about inclusion supports, contact the City of Guelph Inclusion Coordinator at 519-822-1260 ext 2701 or inclusive.recreation@guelph.ca.

    If you have questions about the collection, use or disclosure of this personal information please contact the City’s Information and Access Coordinator at 519-822-1260 extension 2349 or privacy@guelph.ca.

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