RecreationProfile

Child Information Package

Child Information Package

Communication and information sharing between parents/care providers and recreation providers is important when building an inclusive and safe environment.

The information asked for in this package is intended to provide camps, recreation programs and/or leisure activities, insight on your child's strengths and needs. It will take approximately 10 minutes.

This information package will not be saved. The package will only be sent to the email address you specify upon completion. E-mail is convenient, however, security cannot be guaranteed. Additional risks are present when you access e-mail through public places such as the library or an internet cafe. Another person could retrieve the information. Another way of completing the form is to print it, fill in by hand and deliver directly to the recreation program or give to your worker, if one is involved with your family.

Child Details (child named in this form)
First Name :
Last Name :
Date of birth :
Sex :	Male Female
Diagnosis :

General Information
Some of the child's likes :
Some of the child's dislikes :

Communication
Is verbal and capable of making his/her needs and wants known.
Yes No

Understanding
Will understand and follow directions quite nicely.
Yes No

Safety Concerns
Has typical safety concerns.
Yes No

Behaviour
Age appropriate, is usually compliant and co-operative.
Yes No

Social Interactions
Maintains play with others, maintains good relationships.
Yes No

Transitions
Is successful with all transitions.
Yes No

Mobility
Enjoys complete independence with his/her mobility.
Yes No

Personal Care Skills
Is independent with personal care.
Yes No

Participation
Can and will participate fully in all activities.
Yes No

Perseverance
Has the ability to stay with all activities.
Yes No

Recreation Skills
Is successful with most activities/games/sport skills.
Yes No

PLEASE INCLUDE ANY INFORMATION THAT WOULD ASSIST WITH YOUR CHILD’S INCLUSION,
Addtitional Information :

This Consent to Exchange Information section must be completed.

Consent to Exchange Information

I,, parent/guardian, give my consent for the recipient of this document to collect, use and disclose information regarding my child , for the purpose of developing and implementing an Inclusive Recreation Plan. Without limiting the generality of the foregoing, I expressly consent to the exchange of information, including the information contained in this form, personal health information regarding my child, with any organization as may be reasonably necessary for the purpose of developing an Inclusive Recreation Plan, including but not limited to the following entities, their associates and affiliates: Inclusive Recreation Services, Catulpa Community Support Services, Behaviour Management Services of York and Simcoe, Kidz “n” Sports, Community Care Access Centre, Children’s Treatment Network, Simcoe Community Services and New Path Child and Youth Services.

I Agree I Disagree

__________________________________________ February 22,2012
Signature of parent/guardian

Please fill out this box with your email address and a PDF file will be sent to your address:

(Your email address will not be saved and used for any other purpose)

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Child Details (child named in this form)

General Information

Communication

Understanding

Safety Concerns

Behaviour

Social Interactions

Transitions

Mobility

Personal Care Skills

Participation

Perseverance

Recreation Skills

Consent to Exchange Information