Summer Inclusion Service Request

Summer Inclusion Service Request Form

Participant's Name *

First

Last

Nature of Participant's Disability/ies *

Participant's Date of Birth (DD/MM/YYYY) *

Participant's Sex (Optional)

Participant's Gender Identity (Optional)

Has the participant received support through Summer Inclusion Service before?

Parent/Legal Guardian Name *

First

Last

Contact Email *

Primary Phone Number *

Secondary Phone Number

Best method and time to reach parent/caregiver during the day?

Full Address *

Support Requirements *

Please indicate in which areas the participant may require support.

Please elaborate on each area you have selected:

Does the participant have a seizure protocol?

Will the participant require any medication administration during their support time?

Does the participant require any personal care (toileting/dressing/feeding)?

Regarding the nature of SIS with personal care.

Please take a moment to consider how the participant will react to a brand-new worker providing personal care. Since this is a short-term service, there is limited time for relationship building. If a well-established relationship is the key to successful personal care support, this service may not be appropriate. Do you foresee any challenges with personal care?

Does the participant have a Positive Behaviour Support Plan that can be provided to Summer Inclusion Service staff?

Are there any other support requirements that are not mentioned above? If so, please describe:

Does the participant have any triggers that staff should be aware of? What are some suggested strategies for avoiding and/or navigating the behaviour caused by such triggers?

Does the participant use any aids (e.g. wheelchair, walking aids, hearing aids, communication boards or visual aids, app technologies)? If so, will the staff require any training (formal or informal) or specialized knowledge to be able to support the use of these aids?

To aid with matching the participant with a staff member, please provide comments about the participant's interests and personality (e.g. likes singing, dancing, crafts, art, responds well to outgoing personalities):

PROGRAM INFORMATION: What type of support are you requesting?

Requested Week for Support (1st Choice) *

Name and Location of Day Camp (If requesting day camp support)

Alternate Request for Support (2nd choice)

Name and Location of Alternate Day Camp (if requesting Day camp support)

Is there anything else we should know?

Acknowledgement: Short-Term Service *

I acknowledge the short-term nature of this service. I understand that there is limited opportunity for the participant and their Inclusion Support Worker to build a relationship before support commences. I do not foresee any major challenges in this regard.

Acknowledgement: Maximum Hours *

I acknowledge that my request for service is below the maximum of hours per day.

Acknowledgement: Modification or Cancellation *

I acknowledge the importance of notifying Lifetime Networks and the Summer Inclusion Service Director about any changes or cancellations to the request.

Acknowledgement: Breach of Standards *

I understand these minimum requirements and acknowledge that breaching the Summer Inclusion Service requirements may result in loss or termination of service in the future.