ParticiPant intake Form

DATE STAMP
Junior Inclusion Services
Community and Emergency Services
111 Syndicate Ave S.
Thunder Bay, ON P7E 6S4
Fax 625-3395 Tel. 625-3220
Junior Inclusion Services (JIS)
Participant Intake Form
If this is a referral from a service organization (e.g. Dilico, CAS, Children’s Centre, Wesway, etc.)
please complete the Referral Form on page 6 of this package, as well as page 1-5.
If this is not a referral do not complete the Referral Form.
Participant’s Name:____________________________________ Date of Birth: _____________
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Address:__________________________________________________________________________
Postal Code:_________________ Phone Number:_________________________________________
Health Card Number:_________________________________ Expiry Date:______________________
Name(s) of Parent(s) or Guardian(s): ____________________________________________________
Parent/Guardian Tel. #:___________________ Parent/Guardian Tel. #:_________________________
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
No
If ‘Yes’ please describe:______________________________________________________________
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Please describe your child’s interests, activities, pastimes, food, toys etc. that he/she enjoys the most.
Include previous recreation experiences.
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TB398(5)-1(rev02/14)
What recreation activities does your child not like to do? Explain.
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Describe your child’s swimming ability (if requesting support in swimming lessons, or involved in a
program where swimming is part of the schedule).
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Describe your child’s skating ability (if requesting support in skating lessons, or involved in a program
where skating is part of the schedule).
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Describe area(s) where your child requires support or assistance (e.g. transitions, communications,
social settings, personal care, etc).
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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).
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Please list any allergies, medical conditions, disabilities, behaviours, or needs that require special
consideration.
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TB398(5)-2(rev02/14)
Tell us about your child’s ability to interact with other children. What works in case of difficulties?
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Please describe how your child communicates (e.g. verbally, sign language, PEC symbols, etc.)
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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?
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What are calming techniques/environments that work for your child?
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What are 2 goals that you hope your child will accomplish by participating in this program?
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What are your expectations from Junior Inclusion Services?
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As a parent/guardian do you have any additional questions, concerns, or comments?
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TB398(5)-3(rev02/14)
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
Skating
Swimming
Arena Preference: ______________________ Level:_________________________
Pool Preference: ______________________ Level:_________________________
Neighbourhood Recreation Program (age 5-12)
Site Preference:________________________
july to august
Playgrounds (age 5-12)
Chippewa Summer Camps (age 5-13)
Youth Zone (age 12-17)
Canada Games Complex Adventurers Camp (age 5-12)
OTHERSpecify: ______________________________________________________________
Will you be using ProKids?
YES
NO
Photo Consent: Junior Inclusion Services keeps a photo of each participant in our participant files.
Please check this box if you DO NOT wish to have your picture taken for your file.
How did you find out about Junior Inclusion Services?
The Key
A Display Word of Mouth
Newsletter
Presentation
School An Agency
www.thunderbay.ca
Other:______________________
Please sign and date this form. Your signature indicates that the information that you provided is
complete, correct, and current. By signing you also understand that Junior Inclusion Services will
maintain personal information on you while receiving services. This includes statistics, a participant
profile, service notes, and any relevant consent forms.
Date: _________________________ Signature:__________________________________________
Please Return This Form To:
MAIL/DROP OFF
Community and Emergency Services Department
Attn: Junior Inclusion Services – Sarah Swayze
111 Syndicate Ave South
Thunder Bay, ON P7E 6S4
FAX: 625-3395
TEL: 625-3220
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 Community Partnerships, 111 S. Syndicate Avenue, Thunder Bay, Ontario, P7E 6S4, 625-2419.
TB398(5)-4(rev02/14)
REFERRAL FORM
If this is a referral from a service organization (e.g. Dilico, CAS, Children’s Centre, Wesway, etc.)
please include a contact at this service organization, as well as any special instructions. Special
instruction could include if we should have initial contact with the service organization or parent/
guardian.
If this is not a referral do not complete this form.
Organization Making Referral:_________________________________________________________
Staff Name:__________________________________Title: _________________________________
Tel. #:_________________ Cell #:________________Email:________________________________
Special Instructions: ________________________________________________________________
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TB398(5)-5(rev02/14)