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Aquatic Intake Form - Confidential

Town of Aurora Community Services - Inclusion
Please fill out this intake form if you have a participant attending a Town of Aurora Recreation Program who has a disability or unique need.

Personal Information

Participant Name:

Date of birth (MM/DD/yyyy):

Language(s) at Home:

Date form completed (MM/dd/yyyy)

Parent/Guardian Name:

Relationship:

Parent/Guardian Primary Phone #:

Secondary Phone Number#

Email Address

Emergency Contact Information

Name:

Relationship to participant:

Primary Phone Number:

Email Address

Name:

Relationship to participant:

Primary Phone Number:

Email Address

Personal & Medical Information

Diagnosis (please list all diagnoses):

Medical Conditions (i.e. Asthma, Diabetes, Anaphylaxis):

Medication and/or Allergies (i.e. Epi-Pen):