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LAF Swim Lottery
Please provide us with the following information in order to register for the swim lottery!
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* Indicates required question
Swimmer's Name
*
Your answer
Swimmer's Diagnosis
*
Your answer
Parent Email address
*
Your answer
Parent Phone Number
*
Your answer
Can your child swim?
*
Yes
No
Does your child have a history of elopement?
*
Yes
No
Does your child have a history of seizures?
*
Yes
No
Allergies
*
Your answer
Other Medical Concerns
*
Your answer
Does your child display any type of aggressive behavior toward him/herself or others
*
Yes
No
If yes to the question above, please explain:
Your answer
Is your swimmer 100% toilet trained?
*
Yes
No
How does your child communicate?
*
verbal
limited verbal
non-verbal
sign language
augmentative communication device
Other
What are your child's interest(sports/books/games/ect.)?
*
Your answer
What are your child's fears/dislikes?
*
Your answer
Is swimmer in any type of therapy (e.g. occupational, physical)?
*
Yes
No
Can instructor contact therapists to discuss swimmer’s treatment and goals?
*
Yes
No
Please provide the name and phone number of the current therapists. If there are not any therapists please put N/A.
*
Your answer
Is there any additional information we should know?
Your answer
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