Child Support/Inclusion Needs Form

For assistance please email osc@esquimalt.ca

Child Name

Date of Birth

Grade Last Completed

Primary Guardian

Guardian Phone Number

Guardian Email

Child's Diagnosis (if any)

Child's Medications

Health Care Professionals Involved

Recommendations from Health Care Providers

Does your child receive funding from one of the below organizations during the school year

Supported Child Developement

Native Friendship Centre

My child does not receiving funding for support

Other

Child Strengths

Child Needs / Concerns

Triggers

Behaviour Management Strategies

Ex. Needs 15 min warning for transitions

Relevant Documents for Esquimalt Support Staff

IEPs, past care plans, recommendations from school or health care providers, etc.
One file only.
50 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Additional Information for Esquimalt Staff

Esquimalt Parks and Recreation will do their best to provide an inclusion leader for children that are eligible for funding. I understand that submitting this form does not guarantee my child will receive an inclusion worker for camps.

I understand

In the event an Inclusion Worker cannot be provided, Esquimalt Parks and Recreation will contact guardians to process a withdrawal.

I understand

Personal information contained in this form is collected under Section 26 (c) of the Freedom of Information and Protection of Privacy Act and will only be used for the form’s stated purpose. If you have any questions about the collection or use of your personal information, please contact the Corporate Officer at corporate.services@esquimalt.ca or 250-414-7135. More information can be found through our privacy policy.