Required fields are marked with asterisks (*)

Inclusion Service Participant Intake Form

Inclusion Services provides initial facilitation to recreation programming offered by The City of Thunder Bay. This includes use of facilities, services and programs at the Canada Games Complex, 55+ Centre, Community Centre (for city run programs), and Municipal pools and golf courses. Inclusion Services is a free service, however, costs associated with the program must be covered by the participant.

Participant’s Name:

Legal Name:

Pronouns:

Date of Birth

House Number:

City:

Province:

Postal Code:

Phone Number:

Email:

Name of Guardian/Parent/Support:

Guardian/Parent/Support Contact #:

COMPLETE ONLY IF APPLICATION COMPLETED BY REFERRING AGENCY/INDIVIDUAL:

Name:

Organization:

Phone:

Email:

If we need to contact your Guardian/Parent/Support/Spouse/Family Member during program hours and are unable to reach them at the above number, please give the name and phone number of an alternate that we may contact during program hours.

Name:

Phone #:

Relationship to you:

Are friends, family or other individuals currently acting as a support person for you?

Yes

Please provide name(s) of individual(s) and the relationship(s).

Does someone assist you with the following:
If yes, please indicate for each of item how often and what assistance is needed. If no, please indicate with N/A.

Personal Care:

Managing Emotions:

Communication:

Mobility:

Participating in Daily Activities:

What role do you see the Inclusion Services Facilitator playing in your initial use of our services?

Do you use any assistive devices (e.g. wheelchair, hearing aids, etc.)?

Yes

How will you be getting to your activity? (e.g. Lift, taxi, family member, etc.):

What are the best times of day/week for you to participate in recreation activities?

Please describe the recreation activities that you like to do:

Please describe the kinds of recreation activities that you do not like to do:

Please describe any health issues that you have that we need to know about to facilitate your inclusion in recreation activities successfully. Please list allergies, medical conditions, or other needs that require special consideration.

Describe how you communicate. (e.g. verbally, signs, gestures, gazing, etc.)

How would you like to be communicated with during programming?

Tell us about your ability to interact with other people. What makes interactions easier/more difficult for you?

What are some of your goals in being involved in recreation activities? (e.g. fitness, meeting new people, etc.)

Do you have any concerns, comments or do you have any questions regarding your participation in Inclusion Services?

Submitting indicates that the information that you provided is complete, correct and current. By submitting you also understand that Inclusion Services will maintain personal information on you while receiving services. This includes statistics, a personal recreation plan, service notes and any relevant consent forms.

Personal information on this form is collected under the authority of the Municipal Act, R.S.O. 1980,c.302 (as amended) and will be used within the programme for emergency contact and program follow-up. Questions regarding this collection should be directed to the Supervisor of Aquatics and Wellness, 420 Winnipeg Avenue, Thunder Bay, Ontario, P7B 6B7, 684-3338.

Form Builder

Inclusion Service Participant Intake Form

COMPLETE ONLY IF APPLICATION COMPLETED BY REFERRING AGENCY/INDIVIDUAL: