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Parks, Recreation and Community Services Assessment & Accommodation Request

Please correct the field(s) marked in red below:

For additional information, please see our Parks and Recreation Access for All page.
Date completed
Personal Information:
 *
Personal Information:
Participant:
Participant:
 First time participant in a City of Reno program?
First time participant in a City of Reno program?

Health Information

Place a check next to all that applies to the participant and/or write in any other conditions:
Place a check next to all that applies to the participant and/or write in any other conditions:
If "Other" health conditions is selected above:
Does participant have seizures?
Does participant have seizures?
If yes to seizures:
If yes to seizures:
Medications taken? (Please note: Staff will not administer or distribute any medication at any time.) 
Allergies?

Skill Assessment

Please check each statement that applies to the participant. 

Assistance:

Does participant walk independently?
Does participant walk independently?
If not, what type of assistance is required?
If not, what type of assistance is required?
If "Other" assistance is selected above:
Is participant independent in toileting? 
Is participant independent in toileting?
If "No" is selected for toileting:

Communication:

Primary form of language?
Primary form of language?
If "Other" is selected for primary form of language:
Understands what is said to him/her: 
Understands what is said to him/her:
Able to clearly express needs to others:
Able to clearly express needs to others:

Behavior

If the participant was to become agitated, he/she is likely to exhibit:
If the participant was to become agitated, he/she is likely to exhibit:
If "Other" is selected for participant behaviors:
What might trigger a behavior (e.g. over excitement, crowds, certain noises, etc.) 
Please explain any behavior management techniques used at home or school which eliminate or reduce negative behaviors: 
What is rewarding for participant (e.g. verbal praise, smile, etc.)? 

Recreation Activities

 
 
How does the participant interact with others in new settings or with new adults/participants?
Are you receiving services through the Sierra Regional Center?
Are you receiving services through the Sierra Regional Center?
Describe the accommodation you are requesting, and any additional information you feel would assist staff in providing a successful experience for participant. 
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