Required fields are marked with asterisks (*)

Junior Inclusion Service Participant Intake Form

Participant’s Name:

Date of Birth

Gender:

Male

Female

House Number:

City:

Province:

Postal Code:

Phone number

Name(s) of Parent(s) or Guardian(s) 1:

Name(s) of Parent(s) or Guardian(s) 2:

Parent/Guardian Tel. # 1:

Parent/Guardian Tel. # 2:

Email (mother/father/guardian):

If we need to contact you and are unable to reach you at the above numbers, please provide the name and phone number of an alternate contact during program hours:

Name:

Phone:

Relationship to the child:

What is your child/youth's disability?:

Does your child/youth use any assistive devices(e.g. wheelchair)?

Yes

Please describe your child’s interests, activities, pastimes, food, toys etc. that he/she enjoys the most. Include previous recreation experiences.

What recreation activities does your child not like to do? Explain.

Describe your child’s swimming ability (if requesting support in swimming lessons, or involved in a program where swimming is part of the schedule).

Describe area(s) where your child requires support or assistance (e.g. transitions, communications, social settings, personal care, etc).

Are there safety issues or fears that we need to know about? (e.g. fears, distractions, running away, talking to strangers, hitting others/themselves, etc).

Please list any allergies, medical conditions, disabilities, behaviours, or needs that require special consideration.

Tell us about your child’s ability to interact with other children. What works in case of difficulties?

Please describe how your child communicates (e.g. verbally, sign language, PEC symbols, etc.)

How would we recognize that your child is becoming stressed or anxious? Are there factors that cause them to become stressed or anxious that we need to know about?

What are calming techniques/environments that work for your child?

What are 2 goals that you hope your child will accomplish by participating in this program?

What are your expectations from Junior Inclusion Services?

As a parent/guardian do you have any additional questions, concerns, or comments?

SUPPORTS

Your child:

will be attending a program independently

requires one-to-one assistance from JIS to facilitate participation

will be accompanied by a personal support person

PROGRAM CHOICES

Your child is interested in:

JANUARY TO JUNE, & SEPTEMBER TO DECEMBER

Swimming

Programming at the Canada Games Complex (Sept-June)

Neighbourhood Recreation Program (age 5-12)

Youth Move (age 10-18)

JULY TO AUGUST

Playgrounds (age 5-12)

Chippewa Summer Camps (age 5-13)

Youth Move (age 12-18)

Canada Games Complex Adventurers Camp (age 5-12)

Kidventures (age 5-13)

OTHER

Will you be using ProKids?

Yes

Photo Consent: Junior Inclusion Services keeps a photo of each participant in our participant files. Please indicate if you wish to have your picture taken for your file.

Yes

How did you find out about Junior Inclusion Services?

The Key

A Display

Presentation

School

An Agency

Word of Mouth

Newsletter

www.thunderbay.ca

Other

Support Suspended/Cancelled Policy

The Junior Inclusion Services (JIS) program, offered by the City of Thunder Bay, provides a valuable opportunity for children aged 5-18 with disabilities to actively engage in our programs. JIS ensures inclusive participation by offering personalized one-to-one support across various support needs.

In the event that a participants behaviour exceeds our staffing ability, support can be suspended or cancelled until a new plan is developed and in place to provide support in the safest way possible for both the staff and the participant. In these rare instances JIS staff will ensure they have exhausted all support strategies and will keep parent/guardians as up to date as possible. Some behaviours that may result in the cancellation of support are: repetitive aggression or violence towards Facilitators, program staff, oneself, or other participants, recurring events of eloping that raise safety concerns, changing personal care needs and participants that require 2:1 support to maintain safety. Acts of violence encompass behaviors such as biting, hitting, punching, kicking, spitting, pulling hair, throwing objects and other behaviours that put the safety of oneself or others at risk. It is our hope that support can be tailored to meet the needs of your child and we look forward to working with you to make that happen!

Should you have any inquiries or concerns, please feel free to contact us at jis@thunderbay.ca. We are here to assist you.

Form Builder

Junior Inclusion Service Participant Intake Form

SUPPORTS

PROGRAM CHOICES

Support Suspended/Cancelled Policy