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2. 
3. Inclusion & Accommodation Request

   
   

   Longview Parks & Recreation invites individuals with disabilities or needing additional assisstance to join all recreation programs.  Reasonable accommodations will be provided to enable a person to participate at the most independent level.

5. To better serve you, Inclusion & Accommodation Requests should be received at least two weeks before the program begins.  After receipt of this form, you will be contacted to discuss your request and gather additional information if necessary.

7. Participant Name*
8. Parent/Guardian Name*
10. Address*
12. City*
13. State*
14. Zip Code*
16. Phone Number*
17. Email Address*
19. Residency:*

    1. Inside City Limits
    2. Outside City Limits
23. PROGRAM INFORMATION
25. Name of Program:*
26. Anticipated Start Date:*
28. Have you participated in this program in the past?*

    1. Yes
    2. No
29. If yes, date of participation:
31. DISABILITY INFORMATION
33. Primary Disability (as diagnosed):*
35. Secondary Disability (as diagnosed):
37. Has a licensed health professional diagnosed the participant as having the above disability? *

    1. Yes
    2. No
38. If yes, name of licensed professional:
39. Phone:
41. Does the participant take medications we should be aware of?*

    1. Yes
    2. No
42. If yes, please list:
44. Does the participant have an Individualized Education Plan (IEP) or Behavior Plan?*

    1. Yes
    2. No
45. If yes, please list:
47. Mobility Related Issues (use of wheelchair, cane, etc.):
49. Use of Assistive Devices (TTY, read Braille, etc.):
51. Use of Assistive Personnel (interpreter, sighted guide, etc.):
53. Does the participant have seizures?*

    1. Yes
    2. No
54. If yes, what type?
55. Date of most recent seizure:
57. Additional information the program leader/coach/instructor should know about the participant (medical concerns, allergies, behaviors, etc.):
59. ACCOMMODATION INFORMATION
61. What specific accommodations or program adaptions are you requesting?*
63. What accommodations have been used previously?*
65. Specific goals you have for participation in this program?*
67. If applicable, does the participant have a reward system or need assistance with behavioral management?
69. Any additional comments?
73. Participant or Parent/Guardian Signature:*

    By placing your name in this field you therefore agree to the above stated information and allow your name to be your electronic signature.

74. Today's Date:*
    Today's Date:
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field