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Therapeutic Recreation New Participant Form

  1. Burlington Rec Logo
  2. Therapeutic Recreation New Participant Questionnaire
  3. Gender*
  4. Currently taking any medications?*
  5. Will the medication need to be administered/taken by participant, parent, caregiver, or personal care assistant during program hours?*
  6. Does the participant have an IEP?*
  7. Does the participant have a 504 plan?*
  8. Do you give permission for the Therapeutic Recreation staff to contact school personnel and share information?*
  9. Is the participant employed?*
  10. Does the participant have epilepsy and/or experience seizures?*
  11. If yes, please list the following:
  12. Has the participant had any recent serious illness, injury or surgery?*
  13. Does the participant carry an Epi Pen?*
  14. Does the participant follow a special diet we should be aware of?*
  15. Does the participant have a history of heart/lung/cardiovascular problems (Including but not limited to chest pain, blood pressure, cholesterol, asthma, heart attack, heart disease, difficulty breathing, and heart defects)*
  16. Does the participant have hearing/auditory issues*
  17. Use hearing aids?*
  18. Does the participant use ASL/gestures and/or any electronic devices/PECS to communicate?*
  19. Is the participant able to communicate their wants/needs?*
  20. Does the participant speak with a delay/slow speech?*
  21. Please check any of the following activities of daily living where the participant will need assistance*
  22. History of concussions/head injuries?*
  23. Does the participant experience any visual problems/blindness?*
  24. Wear glasses?*
  25. Does the participant have any bone and/or joint problems?*
  26. Any mobility and/or balance concerns?*
  27. Does the participant use any assistive devices or adaptive equipment (walker, crutches, prosthetics, cane, orthotics, etc.) on a daily basis? *
  28. Can the participant read?*
  29. Can the participant write?*
  30. Does the participant have any sensory limitations or concerns that may interfere with programming?*
  31. Does the participant have any psychological, emotional, or behavioral concerns or issues that may arise during social situations, new experiences, physical exertion, or stressful circumstances? (Including but not limited to anxiety, aggression, defensiveness, panic attacks, confusion, etc.)*
  32. The information provided on the previous page is current and accurate. I understand that this is personal information and that it will be confidential, and only pertinent information will be shared with inclusion support staff members on an as-needed basis, and will be kept on file by the Burlington Recreation Department's Therapeutic Recreation Specialist.
  33. School Information Release Form
  34. Burlington Rec Logo
  35. Tips and Tools

    Please fill out this page to give us a better understanding of your child's behaviors, skills and needs.

  36. Burlington Rec Logo
  37. Has your child attended Recreation Department programs before?*
  38. Does your child run away/bolt unexpectedly?*
  39. Does your child exhibit any physically aggressive behaviors? (Ex: hitting, biting, kicking, scratching)*
  40. Does your child show an interest in interacting with their peers?*
  41. Is your child easily agitated/annoyed by others?*
  42. Is your child able to manage their belongings?*
  43. Does your child have a short attention span?*
  44. Does your child prefer independent activities or group activities?*
  45. Is your child able to follow the rules of a game?*
  46. Does your child have difficulty sharing items or taking turns?*
  47. Is your child able to follow directions?*
  48. My child can follow*
  49. Is your child sensory sensitive and/or sensory seeking?*
  50. How does your child do with transitions?*
  51. Are there any tools you use at home or school that might also be helpful during rec programs?*
  52. Tools used for transitions/breaks/activities*

    (Check all that apply)

  53. Will your child ask for a break if they are feeling nervous/overwhelmed/tired?*
  54. If no, are there any signs we should look out for to prompt a break?
  55. Are there any items you will send with your child from home that will help with transitions, to use during a break, or to help your child calm down if upset?*
  56. Will your child tell the staff if they need to use the bathroom?*
  57. Burlington Rec Logo
  58. Burlington Parks and Recreation Department Therapeutic Recreation Programs

    Traveling Emergency Form

  59. Emergency Contact Information

    Must have 2 people to call OTHER than primary contact above

  60. Participant Information:
  61. Does this participant experience seizures?*
  62. Does the participant bolt or run away?*
  63. In case of an emergency- Level of Functional Verbal Communication*

    Choose one.

  64. Leave This Blank:

  65. This field is not part of the form submission.