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What park is the program being offered at?
Would you describe your child’s disability as mild, moderate, or severe? Explain.
What are your child’s fine motor skills/limitations? (grasping, manipulating objects, etc.)
What are your child’s gross motor skills/limitations? (walking, throwing, jumping, etc.)
Does your child have any special medical needs? (Seizure disorders, allergies, dietary restrictions, etc.)
If you answered "Yes" to the previous question, what are those needs?
Is your child on a medication schedule that might conflict with program schedules?
If you answered "Yes" to the previous question, what is that schedule?
Is your child on a toileting schedule that might conflict with program schedules?
Does your child have any special handling for movement difficulties? (positioning,
transferring, dressing, etc.)
If you answered "Yes" to the previous question, please describe:
How does your child communicate?
If you checked "Other" in the previous question, please describe
If your child has difficulty communicating, what is the degree of difficulty?
Is your child usually able to listen to and follow directions appropriately? *
If you answered "No" to the previous question, what is the degree of difficulty?
Where does your child attend school?
Please describe your child's educational services (self-contained classroom, OT, PT, speech, general education school, etc.)
Does your child have interaction with peers without disabilities at school? *
If you answered "Yes" to the previous question, in what kinds of settings?
Does your child have interaction with peers without disabilities outside of school?
Does your child exhibit any behaviors that might interfere with programming? (non-compliance, hitting self or others, tantrums, self-stimulatory behaviors, etc.) *
If yes, please describe those behaviors and note any strategies for avoiding and/or reacting to those behaviors:
Is your child currently on a behavior management program? *
If yes, please describe this program *
What type of reinforcement and/or rewards work best to keep your child motivated?
Is your child oriented to person, place, date, and time?
If there are difficulties, please describe:
Please describe your child’s attention span:
Please describe your child’s problem solving ability:
Please describe your child’s comprehension and retention skills:
Is there anything your child fears?
What does your child usually do during his/her free time?
What are your child’s favorite leisure activities?
Does your child play independently?
If yes, how does he/she usually play? *
Do any other persons play with your child?
If yes, who does your child typically play with and for how long?
Does your child have a friend or sibling who might be willing to be a companion participant in the recreation program?
If yes, who?
What activities does your family enjoy doing together?
What are your goals for your child in this program?
Why did you and your child choose to participate in this particular program?
Do you anticipate that your child will need one-on-one assistance to participate in this recreation program? *
Other concerns, additional comments?
Type of inclusion support you are seeking (check all that apply):*
If you checked "Other" please describe
Lake Hiawatha and Lake Calhoun Beaches Temporarily Closing.
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