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R A L E I G H P A R K S, R E C R E A T I O N A N D C U L T U R A L R E S O U R C E S

18

2016-2017 Registration

(cont.)

Health and Medical Information

Participant’s Name (please print)__________________________________________________________________________________

The City of Raleigh Parks, Recreation and Cultural Resources Department welcomes the participation of all individuals,

including those with disabilities or special needs. We are committed to compliance with the ADA and will provide

reasonable accommodations to facilitate participation in our programs.

To ensure that reasonable accommodations are in

place, program registration or accommodation request should be received at least two weeks prior to the start date of

the program

. For more information, please call Inclusion Services at 919-996-2147.

The City of Raleigh recommends that parents or guardians consult their participant’s pediatrician or health care

professional to assess the participant’s ability to participate in the program. It is requested that parents or guardians

provide in writing any additional instructions for the specific condition or special needs of their participant.

HEALTH INFORMATION

I want Parks, Recreation and Cultural Resources to know about these medical conditions for the participant:

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

I want Parks, Recreation and Cultural Resources to know about these disabilities for the participant:

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

I request ADA accommodation for the disability/medical condition listed.

a

Yes

a

No

If yes, someone from Inclusion Services will follow up with you regarding your request, or you may call Inclusion Services

directly at

919-996-2147

Does the participant have an allergy?

a

Yes

a

No

If participant has any allergy that could result in anaphylaxis (such as tree nut or bee allergy), we strongly encourage

providing your participant with an EpiPen to keep at the program site.

Are you providing an EPI-PEN for use at the site?

a

Yes

a

No

a

Please check here to verify that you will

not

be providing your participant with an EpiPen for the allergy listed above,

that you understand the risks of not doing so and that you release the City of Raleigh from any and all liability regarding

treatment of your child in the event of a life-threatening allergic reaction. In the event of a life-threatening allergic

reaction, program staff will immediately call 911. We do not have EpiPens on site available for use.

Please use space below to provide additional detailed information for anything indicated as “yes” above (including special

instructions for allergic reactions)_ ________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

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