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Urbana Park District
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Participant Information Inclusion Form
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Date of Birth
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Disability/Diagnosis
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Things that I am good at/like to do:
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Things that I am not so good at/don't like to do:
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I communicate by using:
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Help me understand what you want me to do by:
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My social skills with my peers are:
Things that make me happy:
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Things that make me sad or mad are:
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You can tell that I am frustrated/upset when I:
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Things you can do to help me calm down:
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Behavior management techniques that work for me:
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My swimming skills are:
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Medical issues for me are (i.e. seizures, medications, etc.):
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My goals for the program are:
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