Inclusion Profile Form

Inclusion Profile Form

Salt Lake County Parks & Recreation provides opportunities for individuals of all abilities to play sports and participate in County sponsored activities in inclusive environments, as well as in our specialized programming.
Participant Information
Participant's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade
Gender

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Best Phone Number*

Area CodePhone Number
Alternative Phone Number

Area CodePhone Number
E-mail*
Program Information
Name of Program*
Location of Program*
Start Date of Program

MonthDayYear
Date
Diagnosis/Presenting Issue

This Section Required*

	Primary (Check One)	Secondary (Check all that apply)
Allergies*
Attention Deficit Hyperactivity Disorder (ADD or ADHD)
Autism
Behavioral*
Cerebral Palsy
Emotional
Hearing*
Intellectual Disability (ID)
Learning*
Medical Procedure*
Physical*
Seizure*
Traumatic Brain Injury (TBI)
Visual*
Other*

*Please provide more information:

What are your primary goals for enrolling in the program? (Please rate 1 (most important) - 7 (least important))*

	1	2	3	4	5	6	7
Recreation Participation (exposure to a variety of activities)
Recreation activity skill enhancement
Opportunities to experience fun in play
Socialization
Physical fitness/wellness
Improve group participation and social skills
Other

Social & Communication Skills*

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Comprehends and learns through verbal directions
Consistently requires visual aids and modeling to participate in activities
Speaks and is clearly understood
Uses sign language
Initiates conversation and/or seeks contact with peers
Can manage his/her anger when upset
Communicates personal needs
Cooperates with staff and peers; shares
Stays with assigned group with minimal supervision
Becomes frustrated during recreation activities
Avoids or is hesitant about decision making
Maintains personal space
Requires redirecting and prompting to attend to tasks
Can stay on task for 20+ minutes

What strategies/techniques are used at home/school/work to promote positive behavior and/or discourage or redirect inappropriate behavior? Does the customer use a specific behavior plan? (If yes, please provide a copy of the plan.) Please type NA if behavior is not an applicable concern.*
Has the participant ever participated in a similar program before?*

YesNo
If yes, please indicate the type/level of the program.*
What are some of the participant's strengths?*
What are some topics of personal interest to the customer?*
What school does your child attend?*
School name
What type of school setting is your child in?*

Inclusive/Mainstream SettingSpecial Ed Only/Self-contained classroomMixture of Inclusive/Mainstream & Special Ed/Self-containedHomeschoolI'm not sure
May we have your permission to contact the participant's school (if applicable)? If yes, an inclusion staff may contact you to sign an Information Sharing Form. *

YesNo
If yes, we have permission to contact the school, please sign here:

Clear
Under the ADA (Americans with Disabilities Act) you are entitled to reasonable accommodations as a participant with a disability. What specific ADA accommodations are you requesting?*
Is the participant able to use the restroom on their own?*

YesNo
Will the participant need medication distribution or any type of medical procedure during program hours?*

YesNo
If yes, please explain.
An inclusion staff will be in contact with you regarding the information in this form.

If you would like to contact an inclusion staff, please e-mail InclusionRec@saltlakecounty.gov or call (385) 468-1520.

For more information about Salt Lake County Parks & Recreation inclusion services and adaptive programs, please visit our website: https://slco.org/adaptive/
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