Form Center

2. 

4. April 2022

   Dear Parents/Guardians, 

   We are preparing for another summer of fun at Burlington Parks and Recreation! The purpose of this packet is to give you an overview of how inclusion services work, answer frequently asked questions and provide you with all the required paperwork. 

   Our trained support staff members are available to work with participants requesting inclusion support within a ratio that is appropriate for your participant. During the summer, we follow a group inclusion model to allow participants more independence and autonomy. Support staff will be available to provide appropriate social, emotional and behavioral support as necessary, but will only be paired as 1:1 support on an as-needed basis, pending assessment by our therapeutic recreation administrative staff. If your family member requires consistent 1:1 support for medical or behavioral reasons, we welcome their home therapist, PCA, or other aide to attend programs to provide such support after successfully completing a direct service provider packet and CORI background check through our office. I am happy to coordinate with Direct Support Professional's to keep inclusion services consistent for participants. 

   Please read through this entire packet and set up your inclusion meeting with our Therapeutic Recreation Specialist. All forms in this packet are required to be filled out completely and returned to our office as soon as possible. Please fill out the forms thoroughly and accurately as inclusion plans are written based off the information provided in this paperwork, the inclusion meeting and the therapeutic recreation administrative staff's assessment of the participant. The inclusion plans are distributed to the support staff working with your family member so they can form an understanding of how to best support them within our programs. A lot has changed in the past two years with COVID-19 please include any new information regarding your family member.

   Completing the Summer 2022 Inclusion Intake is how you formally request inclusion support within Burlington Parks and Recreation's summer programs. Please note this intake is due by May 11. After May 11 inclusion support requests cannot be guaranteed. 

   If you have any questions regarding the inclusion process, summer programs or the type of support we are able to provide for your participant please do not hesitate to contact me at 781-270-1937 or ejones@burlington.org. We are looking forward to a great summer and hope you are as well! 

   Best,

   Emma Jones, CTRS

6. Helpful Tips before you get started!

   • Fill out all information accurately and completely. 
   • Please be descriptive and honest about how we can best support the participant. 
   • Share IEPs and behavior plans. If there are things that work at school and/or at home that we can carry over to your participant's recreation programs, it may be helpful to keep things predictable and consistent. Examples: token boards, reinforcement schedules, visual schedules, communication boards, reinforcement/preferred items, toys, games and sensory items. 
   • Keep communication lines open! Feel free to email or call with any questions, concerns or feedback that you may have at ANY point over the summer. Drop off and pick up times are a great opportunity to check in with your participant's support staff member or program director, but can get a bit busy. It is a good idea to schedule meetings if you have something you would like to chat about! 

10. Introduction

12. Participant Full Name*
14. Date of Birth*
15. Pronouns*
17. Mailing Address*
19. Name of Primary Guardian/First Contact*
21. Email Address*
22. Cell Phone Number*
24. Participant is registered for the following Summer Programs below:

    Filling out the activity number below does NOT count as registration.

26. 1.
27. Activity #
29. 2.
30. Activity #
32. 3.
33. Activity #
35. 4.
36. Activity #
38. 5.
39. Activity #
41. 6.
42. Activity #
44. 7.
45. Activity #
47. 8.
48. Activity #
50. 9.
51. Activity #
53. 10.
54. Activity #
56. Diagnosis and/or nature of participant's needs*
58. Type of support typically required for participant's success in a recreation setting*

    Choose all that apply.

    1. Group/Social Support
    2. 1:1 Support
    3. ADL/Medical type support/full assistance
    4. Not sure
60. Set up your required inclusion intake interview with Emma Jones, CTRS
    Click here to schedule your phone call

64. Direct Support Professionals

66. A private aid, specialist or behavior therapist will accompany my child to summer programs*

    1. Yes
    2. No
68. If yes, I will provide their contact information and schedule of accompaniment with my child to the therapeutic recreation administrative staff. I understand that they will be required to complete a successful CORI background check at the Parks & Recreation Office at least 2 weeks prior to the beginning of the program they will be attending. I further understand that the specialist accompanying my child must also complete a brief orientation with an administrator of the Therapeutic Recreation Division (either on the phone or in person), and both must complete and sign the Direct Service Professional Packet prior to being allowed to attend programs.
70. Initial and Date
72. Special instructions and/or comments regarding inclusion support for participant*

76. School/Other Provider Release

78. I will provide (or) hereby give permission for my child's teacher to release his/her Individualized Education Plan to the Burlington Parks & Recreation Department, (as well as provide written or verbal communication) for use by the Inclusion Staff.*

    1. Yes
    2. No
80. Signature of Parent/Guardian*
82. Date*
84. I will provide (or) hereby give permission for my child’s provider (ABA therapist, BCBA, Direct Support Provider, etc) to provide written or verbal communication to the Burlington Parks and Recreation Department for use by the Therapeutic Recreation Specialist, Recreation Therapist and Inclusion Staff.*

    1. Yes
    2. No
86. Signature of the Parent/Guardian*
88. Date*

92. Emergency Information

94. Participant Name*
95. Date of Birth*
97. Emergency Contact and Relationship (ex. mom/dad/aunt/etc.)*
99. Emergency Contact Phone Number*
101. Second Emergency Contact and Relationship*
103. Second Emergency Contact Phone Number*
105. In Case of Emergency Independence Level*

     Please choose one.

     1. Complete/Independent
     2. Able to Answer Yes/No Questions
     3. Limited Verbal Skills
     4. Non-verbal
106. Is your child comfortable and safe in/around the water?*

     1. Yes
     2. No
108. *Medications: Please know that we do not have a nurse on staff at Burlington Parks & Recreation (BPRD) programs, and therefore we are not able to hold or administer medications to participants. We can remind participants to take their medications as needed with signed notes from a parent or guardian. Meds must be kept in a safe and appropriate location out of reach of other participants.
110. Participant regularly takes the following medications*
111. Participant will independently take the following medications during BPRD Summer Programs: (please provide type, dosage, and time)*
113. Allergies? If yes, please explain.*
115. Seizures? If yes, please explain.*
117. Aggression? If yes, please explain.*
119. Bolting/Wandering? If yes, please explain.*

123. Behavior

125. Participant's Name*
126. Is the participant able to manage their own belongings?*

     1. Yes
     2. No
     3. With some reminders
128. Does the participant have a short attention span? *

     1. Yes
     2. No
     3. Sometimes
129. Is the participant able to follow the rules of a game?*

     1. Yes
     2. No
     3. Somtimes
131. Does the participant have a hard time losing at games? *

     1. Yes
     2. No
     3. Sometimes
132. Tools used for transitions/breaks/activities: (check all that apply) *

     1. Timers
     2. Reinforcement system
     3. Positive verbal praise
     4. Schedules
     5. Social stories
     6. Verbal warnings/reminders
     7. Sensory items
     8. Frequent breaks
     9. Other
     10. None
134. How does the participant do with activity transitions?*

     1. Great
     2. Ok
     3. Not well
135. Is there anything you do at home/school to help prepare the participant for transitions?*
137. Will the participant tell staff if they need a break?*

     1. Yes
     2. No
     3. Sometimes
138. Are there signs to look out for that the participant needs a break?*
140. Will your child tell the staff if they need to use the bathroom? *

     1. Yes
     2. No
     3. Sometimes needs reminders
142. Connection Builders*

     Please list things your child really loves here!  Be as specific as possible with these preferred topics/activities as this will help our staff connect with participants quicker and help them foster friendships between them and other participants.

144. When I Get Upset*

     Please describe in detail what it looks like when your child gets upset.  Include any triggers or signs to look out for that they may be becoming upset.  This helps our staff to know what to look for and what to expect when your child does become upset.

146. Support Me By*

     Please describe how to best support your child.  List any tips you utilize at home or at school.  Specifically describe what you do when your child does become upset.  For example, do they need space for a few minutes?  Do they do best with a different choice?  Schedules?  Timers?

148. Is your child sensory sensitive and/or sensory seeking?*

152. Goals

154. What are areas for growth for your participant this summer?*
155. What goals do you have for the participant this summer?*

     Please list 3 goals.

159. Physical

161. Does the participant experience seizures*

     1. Yes
     2. No
162. If yes, please provide type, brief explanation, last known seizure, and known triggers
164. All known allergies (please include foods, materials, medications, insects, etc)*
166. Participant requires rescue medications (like EpiPen, inhaler, seizure meds, etc)*
168. Dietary restrictions/ special diet instructions*
170. Mobility: please list any mobility concerns*
172. What mobility device does the participant utilize?

     1. Walker
     2. Wheelchair
     3. Crutches
     4. Cane
     5. AFO
     6. Other
173. Does the participant have a visual impairment?*

     1. Yes
     2. No
174. Does the participant have a hearing impairment?*

     1. Yes
     2. No
176. The participant requires assistance with the following activities of daily living (ADL)*

     1. Dressing
     2. Toileting
     3. Feeding
     4. Mobility
     5. None
177. Describe ADL assistance needed
179. Any other physical wellness information that you would like to share?*

183. Communication

185. Communication - Please describe participant's communication skills and list any tools, devices or methods used as communication aides*
187. Does the participant communicate their needs?*

     1. Yes
     2. No
     3. With prompting
188. Does the participant utilize ASL to communicate?*

     1. Yes
     2. No
     3. Some signs
190. How does the participant process information? Do they need any extra time?

194. Cognitive

196. Describe the participant's cognitive abilities developmentally. Where are they at right now? *
197. How many step directions can the participant follow? *

     1. 1 step
     2. 2 step
     3. 3 step
     4. Needs full assistance
199. What kind of learning style does the participant prefer?*

     1. Visual
     2. Auditory
     3. Modeling
     4. Kinesthetic
     5. Reading & Writing
     6. Other
200. Are there any concepts that are particularly challenging for the participant to grasp? (Ex: Sharing, cleaning up, etc.)
202. Can the participant read? *

     1. Yes
     2. No
     3. Somewhat/Still learning
203. Can the participant write?*

     1. Yes
     2. No
     3. Somewhat

207. Social/Emotional

209. Describe the participant's social behavior*
210. Will the participant initiate interactions with peers?*

     1. Yes with everyone
     2. Yes only with familiar peers
     3. Yes with support
     4. No
212. How can we best support the participant socially? Are there things that you do at home or at school to help them socially?*
213. Conversationally will the participant discuss non-preferred topics with peers?*

     1. Yes will chat about anything
     2. Sometimes
     3. No only likes to talk about preferred topics
215. Does the participant recognize bullying or when someone is being mean/unkind?*

     1. Yes - will let a staff know
     2. Yes - will not report it
     3. No
     4. Other
216. 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.)*
218. Does the participant utilize any coping strategies/tools?*

     1. Choice wheel
     2. Zones of Regulation
     3. Calm down routine
     4. Personal schedule
     5. Calm app/music
     6. Sensory toy/fidget
     7. Other
219. Does the participant recognize and name emotions? Do they have empathy for others?*
221. Describe the participant's relationship with themself. (Ex: What is there self confidence like? Are they tough on themselves? Utilize negative self talk?) *
222. What emotions are we most likely to see from the participant? Ex: Will they be shy at drop-off? Will they become sad or angry if they lose a game? Will they get extremely excited for a new activity?*
224. How can we best support the participant emotionally?*

228. About Me!

229. Please feel free to complete this section with the participant!

231. Add a current photo of your participant here!*
233. My name is*
234. My friends call me*
236. I am _____ years old*
237. The school I go to is ____*
239. I will be in the _____ grade in the fall*
241. My favorite things include*
243. Some things I do NOT like are*
245. Things/Situations that might be hard for me*
247. When I get upset, it looks like this*
249. Here are some things that help calm me down*
251. I'm really good at*
253. Here are some other things I want you to know about me*
Leave This Blank:


255. 1. Receive an email copy of this form.
256. Email address

     This field is not part of the form submission.

257. Submit Submit and Print

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