For additional information, please see our Parks and Recreation Access for All page.

Date completed

Date (mm/dd/yyyy)

Personal Information:

 *

Personal Information:

Name of Participant (First and Last Name)	Date of Birth (mm/dd/yyyy)
Age	Grade
Parent/Guardian Name	Home Phoneext.
Work Phoneext.	Emergency Contact Name
Emergency Contact Home Phoneext.	Emergency Contact Work Phoneext.

Participant:

Participant:

Male

Female

 First time participant in a City of Reno program?

First time participant in a City of Reno program?

Yes

No

Health Information

Place a check next to all that applies to the participant and/or write in any other conditions:

Place a check next to all that applies to the participant and/or write in any other conditions:

Attention Deficit Disorder	Autism
Behavior Disorder	Cerebral Palsy
Developmental Disability	Diabetes
Down Syndrome	Hearing Impairment
Mental Health Issues	Speech Impairment
Spina Bifida	Vision Impairment
Other

If "Other" health conditions is selected above:

Please specify any other health conditions:

Does participant have seizures?

Does participant have seizures?

Yes

No

If yes to seizures:

If yes to seizures:

Please indicate type

Date of most recent seizure:

Medications taken? (Please note: Staff will not administer or distribute any medication at any time.) 

Type of medications, time, dosage, purpose:

Allergies?

Include food/medications/other, activity restrictions, special diets or other medical concerns:

Skill Assessment

Please check each statement that applies to the participant. 

Assistance:

Does participant walk independently?

Does participant walk independently?

Yes

No

If not, what type of assistance is required?

If not, what type of assistance is required?

Wheelchair

Walker

Other

If "Other" assistance is selected above:

Please specify other type of assistance required.

Is participant independent in toileting? 

Is participant independent in toileting?

Yes

No

If "No" is selected for toileting:

Please specify what type of assistance is required.

Communication:

Primary form of language?

Primary form of language?

Verbal

Communication board

Sign language

Pictures

Other

If "Other" is selected for primary form of language:

Please specify other primary form of language:

Understands what is said to him/her: 

Understands what is said to him/her:

Yes

No

Able to clearly express needs to others:

Able to clearly express needs to others:

Yes

No

Behavior

If the participant was to become agitated, he/she is likely to exhibit:

If the participant was to become agitated, he/she is likely to exhibit:

No behavior	Physical aggression
Withdrawn/shy	Attaches self to adults
Verbal aggression	Self injurious behavior
Temper tantrum	Wanders/runs away
Other

If "Other" is selected for participant behaviors:

Please specify other behavior indicators:

What might trigger a behavior (e.g. over excitement, crowds, certain noises, etc.) 

What might trigger a behavior (e.g. over excitement, crowds, certain noises, etc.)

Please explain any behavior management techniques used at home or school which eliminate or reduce negative behaviors: 

Please explain any behavior management techniques used at home or school which eliminate or reduce negative behaviors:

What is rewarding for participant (e.g. verbal praise, smile, etc.)? 

What is rewarding for participant (e.g. verbal praise, smile, etc.)?

Recreation Activities

 

Specify recreation likes:

 

Specify recreation dislikes:

How does the participant interact with others in new settings or with new adults/participants?

How does the participant interact with others in new settings or with new adults/participants?

Are you receiving services through the Sierra Regional Center?

Are you receiving services through the Sierra Regional Center?

Yes

No

Describe the accommodation you are requesting, and any additional information you feel would assist staff in providing a successful experience for participant. 

Describe the accommodation you are requesting, and any additional information you feel would assist staff in providing a successful experience for participant.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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