Adaptive Aquatic Participant Care Form

We are thrilled you are taking a very important step to swim safety! By completing this Adaptive Aquatic Participant Care form, you are providing us important information to schedule your child for an adaptive private lesson. We want to know more about your child so we can help create a program that will best meet their needs. Please complete this form to the best of your ability.  Once you submit this document at the end, it will be sent directly to our Aquatics Director to review and follow-up with you.  Please give us up to 48 hours to respond. 
Participant's First Name
Participant's Last Name
Participant's Date of Birth
Participant's Age
Participant's Gender
Participant's Primary Diagnosis
Participant's Secondary Diagnosis
Parent/Guardian Name
Parent/Guardian Date of Birth
Email
Address
City
State
Zip
Phone (xxx-xxx-xxxx)
Participant's Communication
Participant's Moblity
Participant's Comprehension
Behavior Concerns, Sensory Aversions, Triggers, Fears things that should be avoided:
Techniques that help calm participant:
Identify the participant's strengths:
Identify goals for this program:
Please describe participant's previous swimming experience:
Are you working with a Social Worker that may pay for lessons?
If you are working with a social worker, please provide their name, email address, phone number and county they are located in.
Please share any additional comments:
Days available:
  Monday
 Tuesday
 Wednesday
 Thursday
 Friday
 Saturday
 Sunday
Desired start time:
How did you hear about the Adaptive Aquatic program?
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