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2. Participant Informaton
4. *Please allow RAD team three weeks before program start date to ensure there is adequate time to prepare accommodation for participant.
6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Email Address*
18. Participant Date of Birth
20. Month*
    -- Select One --01 - January02 - February03 - March04 - April05 - May06 - June07 - July08 - August09 - September10 - October11 - November12 - December
21. Date*
    -- Select One --12345678910111213141516171819202122232425262728293031
22. Year*
24. 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
26. Please state your name and relationship to the participant needing an accommodation. Answer N/A if you are the person requesting the accommodation.*
30. Program Information
32. Please select Program Section*

    1. Sports
    2. Aquatics
    3. Teens
    4. Summer Camp
    5. Preschool
    6. Classes
    7. RAD
    8. After School Programs
34. Program/Activity/Class/Event*

    Please include activity number and name

    Example: #12345 RAD Yoga

36. Program Location*
38. Program Dates
    Program Dates Start Date

    —

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

    —

    Start/End Time of Program End Time
41. 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)
43. Additional Accommodation Request Information*

    Please provide details of the accommodation you are requesting.

    And please include any other requests that were not mentioned above.

47. Goal(s) for Participation
49. Please select one or two goals you hope the participant achieves in program.*

    1. Participation in Activity
    2. Socialization with Participants
    3. Improvement of Activity Skills
    4. Improvement of Socialization Skills
    5. Physical Fitness
51. Medical Information
53. Primary Disability
55. Assisted Devices Used
57. Medication
59. Please add other pertinent medical information staff should be aware of

    Example(s): allergies, seizures 

61. Behavior and Communication
63. Check all that apply:*

    1. Comprehends and Communicates Verbally
    2. Has limited Verbal Communication Skills
    3. Initiates Conversation with Others
    4. Maintains Personal Space of Self and Others
    5. Easily Transitions Between Activities
    6. Runs away from Supervision/Activities

    1. One-on-One Assistance/Supervision Needed
    2. Minimal Assistance/Supervision Needed
    3. Self-regulates Aggression/Frustration
    4. Aggressive Towards Self
    5. Aggressive Toward Others
65. 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.

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

    Example 1: If participant is eloping from less favorable activity, staff can talk about Spiderman to help him join the group again.

    Example 2: If participant is getting overstimulated, staff can assist by providing a quiet space or an opportunity for a walk. 

69. Please use the space below to disclose any triggers or signs staff should be aware of before a behavior or situation occurs.*
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field