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Assessment & Needs Form: I Am Me Mentors Swim Instruction
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* Indicates required question
Email
*
Your email
Parent name
*
Your answer
Parent phone #
*
Your answer
Student name (fill out a separate form for every member of the family)
*
Your answer
I would like to start lessons for
*
Fall 2022 (August 27th-)
Spring 2023 (Jan 7th - June 4th)
Other:
Student age
*
Your answer
Most flexible time range available
*
Your answer
What group is your swimmer enrolled in? (Include: time slot, instructor & location) N/A if this form is your first step
Your answer
Which sites are you open to (please be as flexible as possible)
*
CHSRC
Kona Kai
Required
What is your swimmer's prior swimming and swim lesson experience? Please include qualities of the instructor, curriculum or lesson structure that they did or didn't respond well to. This is also the space to explain past trauma's in or around the water (if applicable).
Your answer
How does your swimmer learn best? Check all that apply.
Through practice
Through clear directions
Through watching an exemplar
Through asking questions
Through explanations & analogies
Though fun & engaging activities
Through repetition and patience
Other:
What cognitive, behavioral, physical or mental health support/accommodation needs should we be aware of? This often comes up midway through a course and is most helpful up front so we can accommodate the swimmer best through our lesson planning.
Your answer
Check all that your swimmer can do... (advanced swimmers can skip the first 7 boxes)
Has never entered a pool
Stay calm in pool (with floaties and/or head above water)
Dunk
Swim 2 yards (from wall to lane line)
Swim 5 yards (to blue line)
Swim 12.5 yards (half a pool lenght)
Swim 25 yards (1 pool lenghth)
Swim 50 yards or more (2 pool lengths)
Swim freestyle
Swim backstroke
Swim breastroke
Swim butterfly
Dive
Turn
Pace themselves in a conditioning set
Has swum on a summer league swim team
Has swum on a year-round swim team
Has swum in the ocean
Can confidentially swim in deep ocean water
For competitive swimmers, please list your swim times in key events and time/technique goals for swim instruction.
Your answer
If you believe your swimmer requires private or semi-private lessons, please explain why
Your answer
A copy of your responses will be emailed to the address you provided.
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