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Summer Inclusion Support Application

  1. Summer 2022 Inclusion Intake Title with image of participants kayaking.
  2. April 2022

    Dear Parents/Guardians, 

    We are preparing for another summer of fun at Burlington Parks and Recreation! The purpose of this packet is to give you an overview of how inclusion services work, answer frequently asked questions and provide you with all the required paperwork. 

    Our trained support staff members are available to work with participants requesting inclusion support within a ratio that is appropriate for your participant. During the summer, we follow a group inclusion model to allow participants more independence and autonomy. Support staff will be available to provide appropriate social, emotional and behavioral support as necessary, but will only be paired as 1:1 support on an as-needed basis, pending assessment by our therapeutic recreation administrative staff. If your family member requires consistent 1:1 support for medical or behavioral reasons, we welcome their home therapist, PCA, or other aide to attend programs to provide such support after successfully completing a direct service provider packet and CORI background check through our office. I am happy to coordinate with Direct Support Professional's to keep inclusion services consistent for participants. 

    Please read through this entire packet and set up your inclusion meeting with our Therapeutic Recreation Specialist. All forms in this packet are required to be filled out completely and returned to our office as soon as possible. Please fill out the forms thoroughly and accurately as inclusion plans are written based off the information provided in this paperwork, the inclusion meeting and the therapeutic recreation administrative staff's assessment of the participant. The inclusion plans are distributed to the support staff working with your family member so they can form an understanding of how to best support them within our programs. A lot has changed in the past two years with COVID-19 please include any new information regarding your family member.

    Completing the Summer 2022 Inclusion Intake is how you formally request inclusion support within Burlington Parks and Recreation's summer programs. Please note this intake is due by May 11. After May 11 inclusion support requests cannot be guaranteed. 

    If you have any questions regarding the inclusion process, summer programs or the type of support we are able to provide for your participant please do not hesitate to contact me at 781-270-1937 or We are looking forward to a great summer and hope you are as well! 


    Emma Jones, CTRS

  3. Helpful Tips before you get started!

    • Fill out all information accurately and completely. 
    • Please be descriptive and honest about how we can best support the participant. 
    • Share IEPs and behavior plans. If there are things that work at school and/or at home that we can carry over to your participant's recreation programs, it may be helpful to keep things predictable and consistent. Examples: token boards, reinforcement schedules, visual schedules, communication boards, reinforcement/preferred items, toys, games and sensory items. 
    • Keep communication lines open! Feel free to email or call with any questions, concerns or feedback that you may have at ANY point over the summer. Drop off and pick up times are a great opportunity to check in with your participant's support staff member or program director, but can get a bit busy. It is a good idea to schedule meetings if you have something you would like to chat about! 
  4. Introduction

  5. Participant is registered for the following Summer Programs below:

    Filling out the activity number below does NOT count as registration.

  6. Type of support typically required for participant's success in a recreation setting*

    Choose all that apply.

  7. Direct Support Professionals

  8. A private aid, specialist or behavior therapist will accompany my child to summer programs*
  9. If yes, I will provide their contact information and schedule of accompaniment with my child to the therapeutic recreation administrative staff. I understand that they will be required to complete a successful CORI background check at the Parks & Recreation Office at least 2 weeks prior to the beginning of the program they will be attending. I further understand that the specialist accompanying my child must also complete a brief orientation with an administrator of the Therapeutic Recreation Division (either on the phone or in person), and both must complete and sign the Direct Service Professional Packet prior to being allowed to attend programs.
  10. School/Other Provider Release

  11. I will provide (or) hereby give permission for my child's teacher to release his/her Individualized Education Plan to the Burlington Parks & Recreation Department, (as well as provide written or verbal communication) for use by the Inclusion Staff.*
  12. I will provide (or) hereby give permission for my child’s provider (ABA therapist, BCBA, Direct Support Provider, etc) to provide written or verbal communication to the Burlington Parks and Recreation Department for use by the Therapeutic Recreation Specialist, Recreation Therapist and Inclusion Staff.*
  13. Emergency Information

  14. In Case of Emergency Independence Level*

    Please choose one.

  15. Is your child comfortable and safe in/around the water?*
  16. *Medications: Please know that we do not have a nurse on staff at Burlington Parks & Recreation (BPRD) programs, and therefore we are not able to hold or administer medications to participants. We can remind participants to take their medications as needed with signed notes from a parent or guardian. Meds must be kept in a safe and appropriate location out of reach of other participants.
  17. Behavior

  18. Is the participant able to manage their own belongings?*
  19. Does the participant have a short attention span? *
  20. Is the participant able to follow the rules of a game?*
  21. Does the participant have a hard time losing at games? *
  22. Tools used for transitions/breaks/activities: (check all that apply) *
  23. How does the participant do with activity transitions?*
  24. Will the participant tell staff if they need a break?*
  25. Will your child tell the staff if they need to use the bathroom? *
  26. Please list things your child really loves here!  Be as specific as possible with these preferred topics/activities as this will help our staff connect with participants quicker and help them foster friendships between them and other participants.

  27. Please describe in detail what it looks like when your child gets upset.  Include any triggers or signs to look out for that they may be becoming upset.  This helps our staff to know what to look for and what to expect when your child does become upset.

  28. Please describe how to best support your child.  List any tips you utilize at home or at school.  Specifically describe what you do when your child does become upset.  For example, do they need space for a few minutes?  Do they do best with a different choice?  Schedules?  Timers?

  29. Goals

  30. Please list 3 goals.

  31. Physical

  32. Does the participant experience seizures*
  33. What mobility device does the participant utilize?
  34. Does the participant have a visual impairment?*
  35. Does the participant have a hearing impairment?*
  36. The participant requires assistance with the following activities of daily living (ADL)*
  37. Communication

  38. Does the participant communicate their needs?*
  39. Does the participant utilize ASL to communicate?*
  40. Cognitive

  41. How many step directions can the participant follow? *
  42. What kind of learning style does the participant prefer?*
  43. Can the participant read? *
  44. Can the participant write?*
  45. Social/Emotional

  46. Will the participant initiate interactions with peers?*
  47. Conversationally will the participant discuss non-preferred topics with peers?*
  48. Does the participant recognize bullying or when someone is being mean/unkind?*
  49. Does the participant utilize any coping strategies/tools?*
  50. About Me!

  51. Please feel free to complete this section with the participant!

  52. Leave This Blank:

  53. This field is not part of the form submission.