Therapeutic Recreation Programs
for Individuals with Disabilities
Registration Deadline:
SUMMER 2016
June 3, 2016
Club Rec
(Ages 3-21) Join Club Rec for a fun-filled summer of thrilling adventures and exciting activities that include arts & crafts, special events, physical education,
games, cooking, and field trips! A free lunch is provided. The program is available to all students with special needs and their siblings. Please complete
BOTH SIDES of the Recreation Registration Form and BOTH SIDES of the Club Rec Participant Information Form when registering.
ESY (EXTENDED SCHOOL YEAR) STUDENTS
ESY is “summer school” for students with special needs. This year, ESY is a Monday through Friday program.
Transportation to Club Rec will only be available during ESY weeks. Children must meet certain criteria to participate in
ESY. ESY requires a separate registration form. Please contact your child’s classroom teacher for additional ESY
information and form. Students who register for ESY will attend the afternoon Club Rec program following their morning
ESY classes. Transportation is provided for students to return home if they are enrolled in and bussed to the morning
ESY program and are enrolled in the afternoon Club Rec recreation program at the same location. ESY students
enrolled in Club Rec may participate in the full-day Club Rec recreation program the weeks that ESY is not in session,
but must provide their own transportation to and from the program.
NON-ESY (EXTENDED SCHOOL YEAR) STUDENTS
The morning will be geared toward education and community skills, while the afternoon will be filled with
recreation activities. Non-ESY students must provide their own transportation.
Early Bird Special!!! Register by May 27th and save $20.00 for each 2 week payment of Club Rec.
Registrations received after May 27, will be $200 (resident fee) for each 2 week session!
NO EXCEPTIONS
•
Locations/Ages/Dates:
Elm Street School (Ages 3-12)
900 W. Walnut Ave
Monday-Friday, June 27-August 12 (no program July 4)
(ESY Dates: Monday-Friday, June 27– July 29)
Clement Ave. School (Ages 3 - 21) NEW AGE GROUP
3666 S Clement Ave. (Between E Morgan & E Howard)
Monday-Friday, June 27-August 12 (no program July 4)
(ESY Dates: Monday-Friday, June 27– July 29)
Vincent High School (Ages 12-21)
7501 N. Granville Rd.
Monday-Friday, June 27-August 12 (no program July 4)
(ESY Dates: Monday-Friday, June 27– July 29)
• Times:
Program Time: 9:00 AM-4:00 PM
(ESY Students: 12:00-4:00 PM on ESY dates)
Extended Hours Available: 7:00-9:00 AM and/or 4:00-6:00 PM
No additional cost for extended hours. Please indicate the
participant’s arrival and departure time on the registration
form. ESY students who are bused are NOT eligible for the
extended hours.
•
Resident Fee:
$90 per child per week* by May 27/$100 after May 27
(for children who DO NOT receive state assistance)
$45 per child per week* by May 27/$50 after May 27
(for children who DO receive state assistance)
•
Nonresident Fee:
$180 per child per week* by May 27/$190 after May 27
(for children who DO NOT receive state assistance)
$90 per child per week* by May 2/ $95 after May 27
(for children who DO receive state assistance)
• Payment Schedule: Payment for the first 2 weeks your child
will be attending is due at the time of registration (see schedule
below). Payment invoices will be mailed to your home for the remainder
of the program. You will only be billed for the weeks your child attends.
Payments MUST be made by the due date in order for your
child to continue participation in Club Rec.
Payments are due as follows:
Weeks 1 & 2
Due at registration
Weeks 3 & 4
Due by Friday, July 8, 2016
Weeks 5 & 6
Due by Friday, July 22, 2016
Week 7
Due by Friday, Aug 5, 2016
*Payment note: All students must provide written eligibility
documentation from Wisconsin shares program. Written documentation
must be Food Share / SNAP, Wisconsin shares childcare, or foster care.
If you qualify for the WI Shares-Child Care Subsidy Program or
CLTS Program, please contact your provider before JUNE 6,
2016, to prevent a delay in your child/children's ability to start
Club Rec on time.
Mondays
Smoothie Mania
(Ages 8-99) Lets blend together...smoothies that is!
This class will be thrilling for the taste buds, as
we create delicious smoothies and homemade
juice drinks. We will learn about ways to make
a healthy snack in addition to other tasty
creations!
Location: Hamilton High School
6215 W. Warnimont Ave.
(Back parking lot entrance)
Days/Dates: Mondays, June 27-August 8
Time: 6:00 PM-7:00 PM
Resident Fee: $26 Nonresident Fee: $31
*Fee Note: Plus $8 (cash) due at first meeting for food costs
Game & Card Night
(Ages 8-99) It’s game night! Join your friends for a fun night of
games! We will learn and play card games, in addition to trying our
luck at some of the classic favorites like UNO, Sorry, Trouble and
Pictionary!
Location: Hamilton High School
6215 W. Warnimont Ave
(Back parking lot entrance)
Days/Dates: Mondays, June 27-August 8
Time: 7:00 PM-8:00 PM
Resident Fee: $15 Nonresident Fee: $20
Monday Night Combo
(Ages 8-99) Our Monday Night Combo includes both Smoothie
Mania and Game & Card Night! Sign up for the Combo and save
$5.00!
Location: Hamilton High School
6215 W. Warnimont Ave.
(Back parking lot entrance)
Days/Dates: Mondays, June 27-August 8
Time: 6:00 PM-8:00 PM
Resident Fee: $30 Nonresident Fee: $40
*Fee Note: Plus $8 (cash) due at first meeting for food costs
Tuesdays
Computer Club
(Ages 10-99) Computers are a great resource! Join us as we help
you explore all you can do with a computer. Word processing,
e-mail, Internet, games and more!
(Location: O.A.S.I.S.
2414 W. Mitchell St.
Days/Dates: Tuesdays, June 28-August 9
Time: 6:00 PM-8:00 PM
Resident Fee: $20 Nonresident Fee: $26
Wii Games
(Ages 8-99) Have you tried Nintendo Wii, one of the most active
video games around? We will spend the evening playing various Wii
games. No experience is needed, just come ready to have fun!
Location:
O.A.S.I.S.
2414 W Mitchell St
Days/Dates: Tuesdays, June 28-August 9
Time: 6:00 PM-8:00 PM
Resident Fee: $20 Nonresident Fee: $25
Tuesdays Continued
Splish Splash Swim
(Ages 3-99, All levels) The wave of the future begins with specialized
swim instruction for persons with disabilities, ages 3 and older. We
provide 1 instructor per 4 participants. Swimmers must be at least 3
years old. All tiny tots (ages 3-6 years) must be accompanied in the
water by a parent/adult. Fee is for child only. Persons who cannot
work in a group with 4 students and 1 instructor, are not at least 4ft
tall, or cannot stand independently in 3 1/2 feet of water, must be
accompanied in the water by a parent/adult. Family members and
nondisabled participants are not eligible for lessons. Swimmers who
need assistance in the locker room must provide their own attendant.
Children ages 6 and above must use the appropriate male/female
locker room. Participants must provide their own suit, towel, and
swim cap (caps available at the pool for $2). All swimmers should
wear a swim cap.
Location:
Hamilton High School
6215 W. Warnimont Ave.
(back parking lot entrance)
Days/Dates: Tuesdays, June 28-August 9
Time: 6:55 PM–7:55 PM
Resident Fee: $32 Nonresident Fee: $64
Wednesdays
Scrap & Snack
(Ages 10-99) Do you have photos at home waiting to assemble in an
album? We will show examples and help you create an artistic
memory album. We will take a short break
each week to enjoy a snack and admire each
other’s hard work. Supplies included. Bring
your favorite photos.
Location: Hamilton High School
6215 W Warnimont Ave
(back parking lot entrance)
Days/Dates: Wednesdays, June 29-August 10
Time: 6:00 PM-8:00 PM
Resident Fee: $26* Nonresident Fee: $31*
*Fee Note: Plus $2 (cash) per week for additional supplies & snacks
Thursdays
Culture Cafe
(Ages 10-99) Culture Cafe has been a long time favorite cooking class
and one you don’t want to miss! Join us as we cook and enjoy
delicious dishes from all over the world, in addition to learning fun facts
about the countries they originate from.
Location: Hamilton High School
6215 W. Warnimont Ave.
(back parking lot entrance)
Time: 7:00 PM-8:30 PM
Days/Dates: Thursdays, June 30-August 11
Resident Fee: $26* Nonresident Fee: $31*
*Fee Note: Plus $8 (cash) due at first meeting for additional supplies
Movement/Yoga for Beginners
(Ages 10-99) Come try this relaxing, yet effective form of exercise.
We will focus on the basics: breathing, stretching, beginner moves.
Wear comfortable clothing and shoes. No experience necessary
Location: Hamilton High School
6215 W. Warnimont Ave.
(back parking lot entrance)
Days/Dates: Thursdays June 30- August 11
Time: 6:00 PM-7:00 PM
Resident Fee: $20 Nonresident Fee: $25
Thursdays Continued
Thursdays (Continued)
Thursday Night Combo
(Ages10-99) Our Thursday Night Combo includes both
Culture Cafe and Movement/Yoga. Sign up for the Combo
and save $5!
Location: Hamilton High School
6215 W. Warnimont Ave.
(back parking lot entrance)
Days/Dates: Thursdays, June 30-August 11
Time: 6:00 PM-8:30 PM
Resident Fee: $41* Nonresident Fee: $46*
*Fee Note: Plus $8 (cash) due at first meeting for food costs.
Splish Splash Swim
(Ages 3-99, w/ assistance & 8-99 without assistance)
The wave of the future begins with specialized swim
instruction for persons with disabilities, ages 3 and
older. We provide 1instructor per 4 participants.
Swimmers must be at least 3 years old. All tiny tots (ages 3-6 years)
must be accompanied in the water by a parent/adult. Fee is for child
only. Persons who cannot work in a group with 4 students and 1
instructor, are not at least 4 ft. tall or cannot stand independently in 3
1/2 feet of water, must be accompanied in the water by a parent/adult.
Family members and nondisabled participants are not eligible for
lessons. Swimmers who need assistance in the locker room must
provide their own attendant. Children ages 6 and above must use the
appropriate male/female locker room. Participants must provide their
own suit, towel, and swim cap (caps available at the pool for $2). All
swimmers should wear a swim cap.
Location: Morse– Marshall School (Ages 3 and up w/ assistance)
4141 N. 64th St
(door 9 entrance)
Days/Dates: Thursdays, June 23-August 11
Time: 5:35 PM - 6:25 PM
Resident Fee: $32 Nonresident Fee: $64
Location: Morse– Marshall School (Ages 8 and up independent)
4141 N. 64th St
(door 9 entrance)
Days/Dates: Thursdays, June 23-August 11
Time: 6:30PM-7:30 PM
Resident Fee: $32 Nonresident Fee: $64
We hope you enjoy our summer T.R. programming!
If you have any feedback or
suggestions, please fill out
our evaluations at the end
of the season or call 414647-6065.
Did you know T.R. Programs are offered year
round??
Look for our fall flyer to come out in early
September full of exciting activities offered during
the evenings and weekends.
ALL ACTIVITY
FEES MUST BE
PAID IN CASH
NO EVENING
PROGRAMS
JULY 1 & 4, 2016
Fridays
Diner’s Club
(Ages 13-99) Good friends and great food is what you’ll find
on Friday nights! We’ll create a delicious dinner each Friday
evening that everyone is sure to enjoy! Feel free to bring a
favorite recipe to share and your appetite!
Location: O.A.S.I.S.,
2414 W. Mitchell St.
Days/Dates: Fridays, June 24-August 12 (No program July 1)
Time: 5:00 PM-7:00 PM
Resident Fee: $26* Nonresident Fee: $31*
*Fee Note: Plus $8 (cash) due at first meeting for food
costs.
Moviers and Shakers
(Ages 13-99) If you enjoy movies, music and friends then join
us! This program alternates between a large
screen movie showing and a hip hoppin’
dance party. Either event, it’s a great way to
spend time with friends or learn some new
dance steps. Program registration fee is
nonrefundable.
Location: O.A.S.I.S.,
2414 W. Mitchell St.
Days/Dates: Fridays, June 24– August 12
(No program July 1)
Time: 7:00 PM-9:00 PM
Resident Fee: $5* Nonresident Fee: $5*
*Fee Note: Plus $2 (cash) per week upon entry.
Friday Night COMBO!
(Ages 13-99) Our Friday Night Combo includes both Diner’s
Club and Moviers & Shakers! Sign up for the Combo and
save $5!
Location: O.A.S.I.S.,
2414 W. Mitchell St.
Days/Dates: Fridays, June 24 – August 12
(No program July 1)
Time: 5:00 PM-9:00 PM
Resident Fee: $26* Nonresident Fee: $31*
*Fee Note: Plus $8 (cash) for food costs due at first meeting
Sundays
Sunday Movie Madness
(Ages 13-99) Love movies? So do we; so
let’s enjoy them together! One Sunday
each month we will enjoy an afternoon
matinee at South Shore Cinema. You will
be notified by mail of specific movies and
times after registration. The one-time
registration fee of $5 does not include the
cost of the movie. Program registration fee is nonrefundable.
Location: South Shore Cinema
7261 S. 13 St, Oak Creek
Time: Afternoons/Varies
Days/Dates: Sundays, July10, Aug 7
Resident Fee: $5 Nonresident Fee: $5
Swimming Permission (Signature REQUIRED for Participation)
Parental consent is required for children to participate in a Milwaukee Recreation swimming program and/or field trips that involve
swimming. Please indicate below your child’s swimming ability. Your child will not be allowed to swim without your signature below.
Diapers are not allowed in the pool. Plastic/rubber covers and swim diapers for children ages 3-5 may be purchased at Target, Wal-Mart etc.
Older students can purchase swim diapers through Sprint Aquatics at 1-800-235-2156 or www.sprintaquatics.com.
My child is a non-swimmer. He/she cannot jump in water over his/her head. (Children must be at least 48” tall to stand in most
public pools).
My child is a swimmer. He/she can jump in water over his/her head and swim a minimum of 20 yards without stopping.
My child does NOT have my permission to swim.
Permission is granted for my son/daughter to participate in the swimming activity(ies) as conducted by Milwaukee Recreation. I agree that if a
health condition exists which would limit his/her participation in this activity, I will notify Milwaukee Recreation. I understand that no diapers are
allowed in the pool and I will provide swim diapers or plastic/rubber covers.
________________________________________________________________
Signature of Parent/Guardian/Self
__________________________________
Date
Behavior Information (Signature REQUIRED for Participation)
The Club Rec Program is designed for participants who demonstrate safe and appropriate behavior. Participants should have the ability to
interact positively in a social setting, transition between activities, control emotions and demonstrate self-control. We are unable to support and/
or meet the needs of participants who cannot successfully participate in a 4:1, participant to staff ratio and/or who demonstrate: aggression
(hitting, biting, kicking, spitting) bullying, inappropriate language, inappropriate touching of self or others, threatening behavior, etc. The Club
Rec Program reserves the right, at the sole discretion of its staff, to deem whether the program is appropriate for a participant and/or whether
our staff can support the participants needs. Please answer the following questions:
Yes
No
Is self abusive?
Yes
No
Has difficulty with transitions?
Yes
No
Can be aggressive toward others?
Yes
No
Can work in a 4:1 setting?
Yes
No
Uses inappropriate language?
Yes
No
Uses inappropriate touch (self or others)?
Yes
No
Hits, kicks, bites or scratches? Triggers? __________________________________________________________
Additional behavior concerns we should be aware of: _______________________________________________________________________
___________________________________________________________________________________________________________________
______________________________________________________
Signature of Parent/Guardian/Self
_____________________________
Date
Pick-up Authorization
In order to ensure a safe and fun summer, we are requesting that you list below the people (including yourself) that might be picking up your
child from the Club Rec program. If there is also a person you do not want to pick your child up, please identify them as well. Please do not be
offended if we should ask for some type of identification when picking up your child. We appreciate your cooperation!
Persons who MAY pick my child/children up:
Persons who MAY
NOT pick my child/children up:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Please complete ALL INFORMATION on ALL SIDES of this form (s) and remember to SIGN the
permission section (s). Incomplete registration forms will be returned and delay your
registration. Return registration form with program fees by Friday June 6 , 2016 to:
Therapeutic Recreation
Milwaukee Recreation
Make checks payable to:
2414 W. Mitchell Street
Milwaukee Recreation
Milwaukee, WI 53204
RECREATION OFFICE USE ONLY
DATE RC’VD: ______________________________
AMT: _______________
CHECK #: __________
RECPT #: _________________________________
ESY:
Yes
MEDS
DO NOT RETURN THIS FORM TO YOUR SCHOOL!
INT
No
Pending
TF
CHK
Participant Information
Name:__________________________________________________________________ Preferred Name: ____________________________________
Address:____________________________________________________________City: ________________________________ Zip: ________________
Home PH _______________________________________ Birth Date: ____________________ Age: _____________ Sex:
Male
Female
Email: _________________________________________________________________ Group Home (if applicable):______________________________
Parent/Guardian Info: Name: __________________________________ Home PH: ________________________ Work/Cell PH: ___________________
(Parent/guardian will be contacted first, if parent/guardian cannot be reached, we will call the emergency contact REQUIRED)
Emergency Contact: Name: ___________________________________ Relationship: _______________________ PH: ___________________________
Doctor’s Name: ___________________________________________________________________________ PH: _______________________________
CURRENT School Attending (if applicable): ___________________________________________ Teacher: _____________________________________
Is your son/daughter ENROLLED IN THE 2016 SUMMER EXTENDED SCHOOL YEAR PROGRAM?
Yes
No
If yes, 2016 SUMMER EXTENDED SCHOOL YEAR LOCATION: ___________________________________________________
Program Registration and Fees
SU
F
TH
W
T
M
M-F
Program
Location
Course No.
Resident Fee @ 2 weeks
Club Rec
Clement
1RTR6625–CM01 $180 by 5/27 $200 after 5/27
Club Rec
Elm
1RTR6625–EL01
$180 by 5/27 $200 after 5/27
Club Rec
Vincent
1RTR6625-VN01
$180 by 5/27 $200 after 5/27
Smoothie Mania
Hamilton
1RTR6626-HA1
$26
Game & Card Night
O.A.S.I.S.
1RTR6610-5501
$15
Monday Night Combo
Hamilton
1RTR6627-HA01
$30
Computer Club
O.A.S.I.S.
1RTR6604-5501
$20
Splish Splash Swim
Hamilton
1RTR0501-HA01
$32
Wii Games
O.A.S.I.S.
1RTR6621-5501
$20
Scrap & Snack
Hamilton
1RTR6624-HA01
$26
Culture Café
Hamilton
1RTR6605-HA01
$26
Splish Splash Swim
Marshall
1RTR0501-MR01
$32
Splish Splash Swim
Marshall
1RTR0501-MR02
$32
Movement/Yoga
Hamilton
1RTR6611-HA01
$20
Thursday Night Combo
Hamilton
1RTR6618-HA01
$41
Diners Club
O.A.S.I.S.
1RTR6606-5501
$26
Moviers & Shakers
O.A.S.I.S.
1RTR6612-5501
$5
Friday Night Combo
O.A.S.I.S.
1RTR6623-5501
$26
Sunday Movie Madness So Shore Cinema 1RTR6615-VL01
$5
Payment Choice:
Cash
Check
Money Order
Credit Card (Master Card & Visa Only)
Visa
Master Card
Card Number _______________________
Credit Card Exp. Date _________SSC_____
Cardholder’s Name______________________
Cardholder’s Signature ___________________
Nonresident @ 2 weeks
$360 by 5/27 $380 after 5/27
$360 by 5/27 $380 after 5/27
$360 by 5/27 $380 after 5/27
$31
$20
$40
$25
$64
$25
$31
$31
$64
$64
$25
$46
$31
$5
$31
$5
CHILD/YOUTH DISCOUNT: Sign here for a discount if
your child is 3-21 years of age and is enrolled in food
share/S.N.A.P, WI share childcare, or foster care Classes
$10 and over are eligible for a $5 discount, and classes
$30 and over are eligible for a $10 discount. (except for
Club Rec which is eligible for a 50% discount). Proof of
eligibility is required. Non-MPS students must provide
proof of eligibility with registration.
Signature:
______________________________________________
Total
$_________
$________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
SUB TOTAL
$ ___________
Child/Youth
Discount
$ ___________
TOTAL FEES
ENCLOSED
$ ___________
PLEASE COMPLETE OTHER SIDE
2016 CLUB REC Participant Information Form
IMPORTANT: PLEASE COMPLETE THIS FORM ONLY IF YOU ARE REGISTERING FOR CLUB REC.
Send this form, along with the Therapeutic Recreation Form and program fees due by Friday, June 5, 2015 to: Therapeutic Recreation,
Milwaukee Recreation, 2414 W Mitchell St., Milwaukee, WI 53204.
DO NOT RETURN THIS FORM TO YOUR SCHOOL.
PARTICIPANT’S NAME: _____________________________________________________________________
Location(s)/Weeks Attending
Please check () the location and weeks your child will be attending. You will only be billed for the weeks your child attends. The entire
weekly fee is charged whether your child attends full-time or part-time or 1 day each week or all 5 days each week. Fees will not be prorated.
Elm
Clement
Week 1: June 27-July 1*
(no program July 4)
Week 2: July 5- 8
Week 3: July 11-15
Week 4: July 18-22
Week 5: July 25-29
Week 6: Aug 1-5
Week 7: Aug 8-12*
VINCENT
Week 1: June 27-July 1*
(no program July 4)
Week 2: July 5- 8
Week 3: July 11-15
Week 4: July 18-22
Week 5: July 25-29
Week 6: Aug 1-5
Week 7: Aug 8-12*
Week 1: June 27-July 1*
(no program July 4)
Week 2: July 5- 8
Week 3: July 11-15
Week 4: July 18-22
Week 5: July 25-29
Week 6: Aug 1-5
Week 7: Aug 8-12*
* MPS does not provide transportation for ESY students these weeks. Parent/guardian must provide their own transportation
Transportation Information (ESY STUDENTS) Fill out this section if your child is ENROLLED in ESY
ESY WEEKS (June 27-July 29)
Please check
() the statement that applies
My child will walk to and from the Club Rec Program.
My child will be driven by family/friend to and from the
Club Rec program.
My child will use a transportation/van company, arranged by
parent/guardian, to get to and from the Club Rec program.
Name of Company_____________________________
Phone Number _______________________________
My child is enrolled in the Extended School Year morning
summer school program and MPS will provide bussing to the
morning program and back home at 4:00 p.m. after the Club
Rec recreation program. (Extended Club hours are not
available when using MPS bussing unless you will be dropping
off and picking up your child.)
Bussing Address: ___________________________________
(Only ONE address for pick up and drop off)
Transportation Information (NON-ESY STUDENTS)
NON-ESY WEEKS (Aug1- Aug 12)
MPS does not provide transportation for ESY students during Non-ESY
weeks. Parent/guardian must provide their own transportation.)
Please check () the statement that applies.
My child will not be attending the club Rec program during
Non-ESY weeks.
My Child will walk to and from the Club Rec program.
My Child will be driven by family/friend to and from the
Club Rec program.
My child will use a transportation/van company, arranged
by parent/guardian, to get to and from the Club Rec
program.
Name of Company ___________________________
Phone Number ______________________________
Arrival/Departure Time: Please indicate you child’s arrival and
departure time to and from Club Rec.
Arrival Time: _____________ AM
Departure Time: _____________ PM
Fill out this section if your child is NOT ENROLLED IN ESY
NOTE: MPS does not provide transportation for students not enrolled in ESY. Parent/guardian must provide their own transportation.
Please check () the statement that applies.
My child will walk to and from the Club Rec program.
My child will be driven by family/friend to and from the Club Rec program.
My child will use a transportation/van company, arranged by parent/guardian, to get to and from the Club Rec program.
Name of Company __________________________________
Phone Number ___________________________
Arrival/Departure Time: Please indicate your child’s arrival and departure time to and from Club Rec.
Arrival Time: ______________AM
Departure Time: _________________PM
PLEASE COMPLETE REVERSE SIDE
Health History
Please answer/check  the statements/questions that apply to the participant.




Regular Education (Club Rec Only)
 Cognitively Disabled
 Speech/Language
EBD (Emotional Behavioral Disorder)
 Autistic
 Visually Impaired
Orthopedically Impaired (Physically Disabled)
 Hearing Impaired
 Learning Disabled
OHI (Other Health Impairment)
 Attention Deficit Disorder
 Other: ________________________
Degree of the statement(s) checked above:  Mild
 Moderate  Severe
 Medication Taken?  Yes  No If you answered YES, the following MUST be completed. In case of a medical emergency we
need to know what medication(s) are taken even if medication is NOT taken during recreation program hours.
Name of Medication: __________________________________________________Dose: ________________________________
Time to be Given: ________________________
Possible Side Effects: _____________________________________________
 Asthma:  Yes  No If yes, what is done to control/prevent an attack? __________________________________________
Do you/your child require an inhaler?  Yes  No
 Allergies?  Yes  No If yes, Explain? _____________________________________________________________________
Do you/your child carry an EpiPen?  Yes  No If yes, when should it be used (be specific)? __________________________
 Diabetic?  Yes  No If yes, what shouldn’t you/your child eat or drink? _________________________________________
 Feeding Information:  Independent  Needs some assistance  Needs total assistance  Pureed Food  Tube Fed
 Deaf/Hearing Impaired?  Yes  No If yes, how do you/your child communicate? __________________________________
Interpreter Needed:  Yes  No
 Nonverbal?  Yes  No If yes, can you/your child communicate through a different means?  Yes  No
If yes, Explain?_____________________________________________________________________________________________
 Physically Disabled?  Yes  No If yes, Explain the disability? ___________________________________________________
 Wheelchair/Walker/Cane/Crutch?  Yes  No
If yes, type:  Power Wheelchair  Manual Wheelchair  Walker  Cane/Crutch
Participant is:  Independent  Needs Assistance
 Physical Limitations?  Yes  No If yes, Explain?_______________________________________________________________
 Safety Harness or Gait Belt Required?  Yes  No If yes,  Bus  Classroom  In Community
 Heart Condition?  Yes  No If yes, Explain? __________________________________________________________________
 Seizures:  Yes  No If yes, Explain what happens before the seizures________________________________________
If yes, frequency of seizures? _____________________________ Date of last seizure? _________________________________
 Exposure to Sun?  Full  Minimum  No Exposure  Sunscreen may be used
 Swim Experience?  Yes  No If yes, previous swim experience level & location_____________________________
 Toileting Information?  Toilet Trained  Needs some assistance  Needs total assistance  Wears Diapers
If assistance is needed, what is procedure/schedule? _______________________________________________________
 Are there any health/medical concerns that require special care/handling (such as hepatitis B or C, HIV, hemophilia, stroke,
etc.)? __________________________________________________________________________________________
Permission/Waiver Form (Signature REQUIRED for Participation)
PERMISSION: I hereby grant permission for my child/myself to participate in the above-named MPS Recreation event. In the event of an injury requiring medical
attention, I hereby grant permission to the recreation staff (including volunteers) to attend to my son/daughter or myself including seeking medical attention.
WAIVER: I/we recognize that unanticipated situations and problems can arise during Recreation activities that are not reasonably within the control of the recreation
staff (including volunteers). I/we therefore agree to release and hold harmless the Milwaukee Board of School Directors, its agents, officers, employees, and volunteers,
from any and all liability, claims, suits, demands, judgments, costs, interest and expense (including attorneys' fees and costs) arising from such activities, including any
accident or injury to myself or my child and the costs of medical services.
PHOTO RELEASE: I understand, as parent/legal of the above-named child, that there are times when the local news media national news media and/or nonprofit
organizations partnering with Milwaukee Public Schools request the opportunity to videotape, take photographs and/or interview children within Milwaukee Recreation and
Milwaukee Public Schools. By signing this, I understand that and give permission for MPS to allow this with respect to my child. I also understand that by signing this release
I give permission to the Milwaukee Public Schools to make or use pictures, slides, digital images, or other reproductions of me, of my minor child or of materials owned by
me or my child, and to put the finished pictures, slides, or images to use without compensation in broadcast productions, publications, on the Web, or other printed or
electronic materials related to the role and function of the Milwaukee Public Schools. I understand that by signing this, I am, on behalf of myself and my child, releasing MPS
and its directors, officers, employees and agents, from any future claims as well as from any liability arising from the use of any photograph or other images. This form shall
be valid for the duration of the current Milwaukee Recreation program season.
I HEREBY CERTIFY THAT I HAVE READ AND DO UNDERSTAND THE ABOVE INFORMATION:
_______________________________________________________________________________ _____________________________________________
Signature of Parent/Guardian/Self
Date
Prescription Drug Authorization Form
• TO BE COMPLETED BY PARENT/GUARDIAN •
Name
MPS
Student I.D. #
Date of
Birth
Address
City
Zip Code
Please Check
Recreation Location:
 Elm Creative Arts  Gaenslen  Hamilton  Victory  Other: _________________
To Recreational Personnel:
I am requesting that my child, _______________________________________, receive prescription drugs at the time
indicated and as designated below by his/her physician.
I will be responsible for bringing the prescription drugs to school in a labeled container from the pharmacist. I also
understand that I am responsible for maintaining a sufficient quantity of the medication at the school to avoid any
interruptions in the physician’s orders. Failure to do this will result in termination of the recreation program’s
administered medication system for my child.
I understand that if my child refuses the prescription drug(s), force will not be exerted by recreation personnel to
make him/her comply. I also understand that the information regarding prescription drugs can be shared with the
recreation program staff. If medications should change mid-season, a new Prescription Drug
Authorization Form will need to be completed.
_____________________________________________________________________
Signature of Parent/Guardian
__________________________________
Date
• TO BE COMPLETED BY PHYSICIAN •
To Recreational Personnel:
I am prescribing medication for ________________________________________ which is described below. I understand
that these orders will be shared by the recreation staff personnel. These orders shall be effective through
_________/_________ unless they are discontinued, changed by me, or withdrawn in writing by the parent/guardian.
Month / Year
Name of Medication
(Generic & Trade Name)
Dosage
Time
(Specify AM/PM)
Possible Adverse
Side Effects
______________________________________
____________________________
_________________________
Signature of Physician
Office Phone Number
Date
RETURN COMPLETED FORM TO:
Therapeutic Recreation
Milwaukee Recreation
2414 West Mitchell Street
Milwaukee, Wisconsin 53204-3025
Phone: (414) 647-6065
Fax: (414) 647-6079
Division of Recreation and Community Services
Therapeutic Recreation Programs for Individuals with Disabilities
LM 050313
Name
• TO BE COMPLETED BY RECREATION PERSONNEL •
Date
Administered
Time
Administered
Medication
Administered
Dosage
Signature of Staff Member
Administered Administering Medication
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