Inclusion Form

Complete and submit to the City of Tempe Community Services Department prior to the start of the class, program or activity the accommodation request pertains to. All sections need to be completed.

For more information, visit tempe.gov/play and review the City of Tempe Inclusion Program.

Name of Participant: _____________________________________ Date of Birth : _____________________ Name of Parent/Legal Guardian: ______________________________________________________________ Address: _________________________________________________________________________________ City: _______________________ State: _________ Zip Code: __________ Tempe Resident? YES/NO Primary Phone Number: _______________________ Secondary Phone Number: _____________________ Email Address: ____________________________________________________________________________

Program, Class or Activity Name: ______________________________________________________________ Program, Class or Activity Code: ______________________________________________________________ Location: _________________________________________________________________________________ Dates of program, session or season: __________________________________________________________ Has the registrant previously participated in City of Tempe Programs before? YES/NO Has the registrant previously participated in City of Tempe Adaptive Recreation Programs before? YES/NO

____ Adaptation or modification of instruction ____ Assistance with Vision or Hearing Impairment ____ Adaptation or modification of equipment ____ Sign Language Interpreter ____ Other [please explain]: _________________________________________________________________

Please share details that you feel are important for us to know when reviewing this request.

This form may be submitted the following ways: 1. Email: Samantha_Mason@tempe.gov 2. Mail: Tempe Adaptive Recreation, Attn: Samantha Mason, 3500 S. Rural Rd., Suite 201 Tempe, AZ 85282