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
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
. 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.
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.
If yes, someone from Inclusion Services will follow up with you regarding your request, or you may call Inclusion Services
Does the participant have an allergy?
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?
Please check here to verify that you will
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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