All about me - Inclusion support request form

Help us provide your child with the best experience possible by sharing some important information with us.

Contact information

Participant's Name:

Participant's age:

Parent or Guardian's name:

Email address:

Phone number 1:

Phone number 2:

Emergency contact name:

Relationship to the participant:

Phone number 1:

Phone number 2:

We try to accommodate individuals with various special needs, including intellectual or physical disabilities, behavioural challenges, vision and hearing impairments, or medical conditions that prevent participation in a program or service without additional support. Support can be provided by Municipality of Clarington Inclusion staff or a support worker provided by the participant or their family.

What type of support are you looking for?

Requesting inclusion support from the Municipality of Clarington

Providing your own support worker

Other

Participant's exceptionality

Diagnosis (please list all)

Sensory and behaviour information

Please check any common behaviour the participant exhibits.

Aggressive towards others (please explain below)

Attention seeking

Hyperactivity

Non-compliant

Profane language

Self-injures

Self-stimulation

Temper tantrums

Other

Please share any other information about the participant’s behaviours and effective suggestions to deal with those behaviours.

Form Builder

All about me - Inclusion support request form

Contact information

Participant's exceptionality

Sensory and behaviour information