Required fields are marked with asterisks (*)

City of Cambridge Leisure Buddy Application & Participant Information

(For children who require additional staff support in recreational programs)

We would like to make your child’s leisure experience a success. Please help us by completing the following information. The information you provide will be used to arrange for appropriate support and to assist recreation staff to make your child’s experience positive.

Child's Name

Program

Home Address

Email Address

Child's Age

Child's Sex

Child's Birth Date

1. Name of Parent/Guardian

Home Phone

Work Phone

Cell Number

2. Name of Parent/Guardian

Home Phone

Work Phone

Cell Number

3. Please describe your Child’s disability or special need (please be specific).

4. Please identify what type of assistance you child receives at home and at school.

5. Please identify what type or assistance your child will require to participate in a recreational Program (Please be specific).

6. Does your Child use a wheelchair?

Yes

Manual

Electric

7. Does your Child use any other type of equipment in everyday activities or tasks? (braces, canes etc).

8. Please indicate your Child’s level of independence in mobility.

Dependant

Assistance Required

Independent

9. Please indicate your Child’s level of independence in transfers.

Dependant

Assistance Required

Independent

10. Please indicate your Child’s level of independence in dressing.

Dependant

Assistance Required

Independent

11. Does your Child wear a diaper?

Yes

12. Does your Child require assistance with toileting?

Yes

If yes, please describe assistance required:

13. Please describe your Child’s behavior in terms of activity level, attention span, impulsiveness, etc.

14. Please identify any triggers that may initiate a behavioral outburst:

15. Please indicate any strategies/techniques that you find useful in managing your Child’s behavior:

Upon review of this application, a staff representative from the municipality will contact you to discuss your request.

City of Cambridge Leisure Buddy Application & Participant Information

Vision: The vision of the program is to facilitate the provision of recreation opportunities for individuals with disabilities, so that all people have the opportunity to participate in the programs and activities of their choice.

Our Goal: To provide support to persons with disabilities who require varying levels of assistance to access and participate in both municipal and community based programs.

Who Can Request a Leisure Buddy? Persons with a disability who are unable to independently access recreation programs without support, who are between the age of 3 and 25 can access the Leisure Buddy Program.

The Process:

Step 1: Complete the online application or mail, fax, to:

Natalie Verschueren, Recreation Coordinator - Child and Youth
City of Cambridge
50 Dickson Street, PO Box 669
Cambridge, ON N1R 5W8
Fax: (519) 740-6566

Requests for support should be made No Less than 2 weeks prior to the program start date.

Step 2: Upon receiving your application, a staff representative from the City of Cambridge will contact you to discuss and attempt to arrange suitable support through either a staff or volunteer worker.

Matching the Participant with a Leisure Buddy: Please note that every effort is made to find a suitable Leisure Buddy, however matching is based on availability of volunteers and staff.

For more information about the Leisure Buddy Program contact:

(519) 623-1340 ext. 4640
Or email verschuerenn@cambridge.ca

Personal information in relation to this process is collected under the authority outlined in the Municipal Freedom of Information and Protection of Privacy Act. This information will be used only for the purpose for which it is intended. If you have any questions regarding this collection of personal information, you can contact the Freedom of Information and Privacy Coordinator, who can be reached through the Clerk’s Office at (519) 740-4680. Ext 4583.

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City of Cambridge Leisure Buddy Application & Participant Information