Assistance Request

Assistance is provided for participants upon request.

Blue Valley Rec prohibits the discrimination on the basis of race, color, national origin, sex, gender, age, religion, genetic information, pregnancy status, disability, sexual orientation, veteran status, and any other status protected by law in employment and its programs, activities, and services. BVRC complies with the Americans with Disabilities Act (ADA), under which qualified individuals with a disability may be entitled to reasonable accommodations in programs, activities, and services of and in employment with BVRC.

Question Title

* 1. Email Address

Question Title

* 2. Your First, Last Name

Question Title

* 3. Your Contact Number

Question Title

* 4. Name of Participant to Receive Assistance

Question Title

* 5. Type of assistance requested

ASL Interpreter

Inclusion Helper

Question Title

* 6. BVRC Program/Activity Name

Question Title

* 7. Reason(s) for Assistance (please be specific so we can better understand how to help)

Question Title

* 8. Start date of Program/Class/Activity

Date / Time

Date

Time

AM/PM

Question Title

* 9. How will the Inclusion Helper assist the participant during program/class/activity? (check all that apply)

Academic support (reading, note taking, explanations)

Behavioral support

Social skills

Assisting with skills

Physical support

Question Title

* 10. Are you or a family member also willing/able to provide assistance during the program/class/activty?

Yes