Skip to main content
SEARCH THE Y
Main navigation
Live Schedule
Y360
Membership
Join the Y
Financial Assistance
Corporate Membership
Nationwide Membership
Mission Partner Membership
Refer a Friend
About
Facilty
Take a Virtual Tour
Meet Our Staff
Board of Directors
Employment
Diversity, Equity, & Inclusion
Programs
Program Guide
Summer Camp
Mahomet Summer Camp
Y on the Fly Summer Program
Aquatics
Swim Lessons
Aqua Fitness
HEAT Swim Team
Masters Swim
Lifeguard Training
Active Older Adults
Birthday Party & Event Rentals
Child Care
After School Program
Child Watch
Schools Day Out
Parents Night Out
Y Hangout
Climbing Wall
CPR Certification
Girls on the Run
Health & Fitness
Group Fitness
Personal Training
Virtual Wellness
Wellness Programs
SURVIVOR CHALLENGE
YMCA 5K Run/Walk Program
Homeschool PE
Knit & Crochet Club
Sports & Recreation
Adult Sports
Youth Sports
Y on the Fly
BOYS - Building Opportunities for Youth Success
DYNO Dance Team
Larkin's Place
About
Inclusion
Basketball for All
Therapy Services
Cookin It Up
Friday Night Fun
Gamers
John's Friends
Nemo Swim Lessons
Soccer for All
Parent Resource Series
Parent Support Group
Art for All
Developmental Playgroup with DSC
Move Shake Adaptive Dance
Neurodiversity Groups
Wheelchair Basketball
Events
Give Back
Annual Campaign
Banner Program
Volunteers
Planned Giving
User account menu
Join
Donate
Login/Register
Toggle Menu
User account menu
Join
Donate
Login/Register
Stephens Family YMCA
Find Y and Camp Locations
Go
Main navigation
Live Schedule
Y360
Membership
Join the Y
Financial Assistance
Corporate Membership
Nationwide Membership
Mission Partner Membership
Refer a Friend
About
Facilty
Take a Virtual Tour
Meet Our Staff
Board of Directors
Employment
Diversity, Equity, & Inclusion
Programs
Program Guide
Summer Camp
Mahomet Summer Camp
Y on the Fly Summer Program
Aquatics
Swim Lessons
Aqua Fitness
HEAT Swim Team
Masters Swim
Lifeguard Training
Active Older Adults
Birthday Party & Event Rentals
Child Care
After School Program
Child Watch
Schools Day Out
Parents Night Out
Y Hangout
Climbing Wall
CPR Certification
Girls on the Run
Health & Fitness
Group Fitness
Personal Training
Virtual Wellness
Wellness Programs
SURVIVOR CHALLENGE
YMCA 5K Run/Walk Program
Homeschool PE
Knit & Crochet Club
Sports & Recreation
Adult Sports
Youth Sports
Y on the Fly
BOYS - Building Opportunities for Youth Success
DYNO Dance Team
Larkin's Place
About
Inclusion
Basketball for All
Therapy Services
Cookin It Up
Friday Night Fun
Gamers
John's Friends
Nemo Swim Lessons
Soccer for All
Parent Resource Series
Parent Support Group
Art for All
Developmental Playgroup with DSC
Move Shake Adaptive Dance
Neurodiversity Groups
Wheelchair Basketball
Events
Give Back
Annual Campaign
Banner Program
Volunteers
Planned Giving
Breadcrumb
Home
Inclusion Form
Inclusion Form
Current
Page 1
Page 2
Page 3
Complete
Contact Information
First Name
Last Name
Today's Date
Email Address
Disability
Date of Birth
What Should We Know?
Things that make me happy and that I enjoy doing are:
Things that make me unhappy and that I do not enjoy doing are:
I am good at:
I am not so good at:
I love talking about:
The best ways to transition to a new activity is by:
If you want to get and keep my attention, you should:
When I begin to get upset, I:
If I begin to become upset, the best ways to support me are:
Does your child have behavioral concerns at home or in the classroom?
No
Yes
Please Explain
Check all that apply:
Wander or leaves the group
Will Take others belongings
Will ask for assistance when needed
Easily distracted/difficulty focusing
Put self at risk
Physically aggressive to others
Verbally aggressive to others
Recognizes danger
Runs away/flight risk
Has Specific Triggers
No
Yes
Please Specify
Has specific fears/concerns to be aware of:
No
Yes
Please Specify