Required fields are marked with asterisks (*)

Inclusion Support Request Form - Under 18 years

Please complete this form with as much detail as possible, so we can ensure that we are providing the participant with the best experience.

It takes about 15 to 20 minutes to complete the form depending on the participant's needs. You can complete the form in multiple sessions using the save button at the bottom of each page to save your progress and return to it later.

Please note that to accommodate each participant's changing needs, you must complete the form annually (typically in the spring) or as needed if your needs change before the annual date.

Participant first name

Participant last name

Age

Date of birth

Developmental level

Preferred age of group members:

Contact Information

Primary contact first name

Primary contact last name

Relationship to participant

Phone number

Alternate phone number

Secondary contact first name

Secondary contact last name

Relationship to participant

Phone number

Alternate phone number

We try to accommodate individuals with various support requirements. This can include, but is not limited to, intellectual or physical disabilities, behavioural challenges, the need for sensory-based accommodations, or medical conditions that prevent participation in a program or service without additional support.

Everyone should be able to work in a safe and healthy workplace. The Occupational Health & Safety Act sets out roles and responsibilities of workplace parties with respect to workplace violence and workplace harassment, including developing and implementing policies and programs and providing information and instruction on these. The Municipality of Clarington adheres to this legislation. Therefore, if a participant exhibits behaviours (such as high levels of aggression or fleeing the facility) that put the safety of staff and other participants at risk, then this program may not be the level of care that the participant requires to ensure a safe environment for all and will be cause for their removal.