Required fields are marked with asterisks (*)

Participant Information Form

We are committed to making our programs and leisure activities available and accessible. It is our goal to make your child's time with us a positive experience!

Please help us by completing the following information. The information you provide will be shared with our staff/volunteer team to provide support to your child within the program setting.  

Contact Information

Emergency Contact (during program time when parent/guardian is unavialable)

Child's Information

Does your child have a disability or special need?

Is your child verbal? If no, please fill out participant non-verbal form
Does your child require assistance with toileting?
Does your child wear diapers?
Pull Ups?
Bladder Control?
Bowel Control?

Please rate your child's physical skills by choosing the appropriate number

Learning new skills
Fine motor tasks
Does your child have hearing difficulty?

Does your child have vision difficulty?

Please rate your child's skill level by choosing the appropriate number

Is your child comfortable in a group environment?

Does your child attend school?
Does your child communicate with?
Does your child find transitions?

Level of Support

Please indicate the required staff-to-participant ratio. Ratio range from 1:1 to 1:3


Please indicate your child's swimming skill level

Behaviour Information

Please indicate if your child exhibits any of the following behaviours and their triggers

Pulling Hair
Refusal to participate
Does your child display self-injurious behaviour?

Medical Information

Please list all medications, even if not taking at camp

Is medication required during program activities?
Please indicate if your child has any of the following health and safety alerts
Does you child carry a puffer?
Does you child carry an EPI-Pen?

If yes, please complete Consent for Administration of Epi-Pen Form

Camp Weeks 

Week 1 June 29 - July 2 Week 6 August 3 - August 6
Week 2 July 5 - July 9 Week 7 August 9 - August 13
Week 3 July 12 - July 16 Week 8 August 16 - August 20
Week 4 July 19 - July 23 Week 9 August 23 - August 27
Week 5 July 26 - July 30 Week 10 August 30 - September 3

Staff will follow up to let you know what weeks you are registered for. If your child has a sibling or friend attending camp with them, please provide that child’s name below. Siblings will be automatically scheduled for the same week unless parent/guardian request otherwise.


If you are sending a worker to attend the program with your child, please complete the Support Worker Information Sheet

Program Information

  • Support for children with special needs is available only for programs provided through the City of Cambridge – Not Private Programs.

  • To be eligible for support, a child must be willing and able to participate (with assistance) in at least 50% of the program activities.

  • Staff will assist in selecting an appropriate program for your child; SunBlast, Imagination Station or 1:1 Support in a Community Program setting.

  • Children should not be accessing both specialized programs and 1:1 support through City run playgrounds and camps.

If your summer plans change, please contact Natalie Verschueren, Recreation Coordinator Child & Youth, at 519-623-1340 ext. 4554 or

Permission and Consent

In order to maximize the benefits and enjoyment derived from this program and to offer the best support possible, I understand that it is important for the staff to have a clear idea of the capabilities of the program participants. The above information is true, accurate and includes as complete a description as possible. I hereby, authorize City of Cambridge staff to obtain/release information on my child who will be participating in the program. The purpose of the information is to enable the staff, instructors and volunteers to plan the sessions to meet the needs of the participants. I permit my child (listed below) to participate in the program. I understand that this information is to be used by the recipient for the purpose of program planning, development and accommodation/support.

I agree

Permission for Photographing and Videotaping


Behaviour Expectation

The City of Cambridge summer program staff are dedicated to providing your child with a safe, creative and innovative program that will peak their interest and keep them enthused.  We have fun, play fair, and show respect for ourselves and for others.

The rules of program participation will be clearly outlined to participants 

  1. Keep your hands and feet to yourself
  2. Speak nicely to each other
  3. Touch only what belongs to you
  4. Stay within the activity area
  5. Listen to your leaders/staff

It is the intention of staff to provide a fun and safe program environment for your child.  Summer program staff have been trained in a variety of behaviour management techniques to encourage positive behaviour and self-discipline. Keep in mind this is a camp/playground environment with no therapists on site. Playground staff and Inclusion Facilitators will not use physical restraint.  Personal care such as toileting, diapers, lifts and transfers will be the primary responsibility of the family - agency support may be arranged through Inclusion Services when necessary.

Program Expectation

To ensure the best use of resources and the success of our programs, we ask the following program expectations be reviewed; 

  • Ensure drop off and pick up times are followed
  • Inform staff when participant is sick prior to program start time
  • Inform Inclusion Coordinator if child is being withdrawn from program
  • Ensure staff are aware if a support worker or therapist will be on site during program

Contact Information

For information on programs, support and accommodation contact;

Natalie Verschueren
Recreation Coordinator Child & Youth
519-623-1340 ext. 4554


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.