Inclusion Intake Form

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.
Participant name*

First nameLast name
Date of birth*

MonthDayYear
Date
Name of person completing this form*

First nameLast name
Phone number*
###-###-####
Email*
example@example.com
Relationship to participant*

Parent/guardianParticipantOther
Has the participant received support from inclusion services before?*

YesNo
Please specify support received

Consent and acknowledgement
Date submitted

MonthDayYear
Date
Status
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.
Should be Empty:

	Difficult/hard	Somewhat difficult	Somewhat easy	Easy/strong
Balance
Coordination
Fine motor tasks

	Independent	Assistance required	Dependent
Dressing/undressing
Mobility
Transfers (eg. moving from a chair to the floor, or siting to standing)

	Easy	Sometimes challenging	Challenging
Making friends or socializing with peers
Understanding and responding to social conversations
Reading social cues or body language of conversational partners
Transitioning into new topics during conversation
Listening and/or participating in small group instruction
Following instructions with 2 or more steps

Inclusion Intake Form

Section 1: Strengths and interests

Section 2: Medical information

Section 3: Physical skills and activities of daily living

Section 4: School and support needs

Section 5: Communication and social skills

Section 6: Sensory and behaviour information

Consent and acknowledgement

Collection of personal information