Adaptive Dance Intake Form

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Please complete this brief intake form. This information will help with class preparation and instructor education as we strive to make this a therapeutic and fun experience for dancers of all abilities! For any questions, please email Rain Peruggi at rain@boulderballet.org

We respect your and your child's privacy and medical information collected. Information collected via this form and in-person will be used to provide the dancer the best experience possible with our adaptive dance program. If you would prefer to thill this form out by hand, please print this page and email a copy to one of the above email addresses. Thanks!

Email *

Student Name

Dancer's age

Dancer's date of birth

YYYY

Parent(s)/Guardian(s) name(s)

Phone number (parent/guardian)

Email address (parent/guardian)

Emergency Contact (Please use the name of someone outside the home who can be contacted in an emergency if the legal guardian(s) of the child cannot be reached)

Emergency Contact phone number

Dancer's primary care physician name

Dancer's primary physician phone number

Dancer's primary medical diagnosis/diagnoses affecting impairment. Please be specific (e.g. cerebral palsy, autism spectrum disorder, Down syndrome, spina bifida, etc.)

Does the dancer have any other medical diagnoses or concerns (e.g. asthma, seizure disorder, heart disease, vascular disease, etc.)?

Option 1

Clear selection

Please list the dancer's past surgical procedures, if any (including approximate dates)

Please list an special medical/health precautions (include past and present seizure activity, activity restrictions made by a physician, allergies, etc.)

Please list any medications the dancer takes (including dosage, frequency, and reason for medication)

Dancer's height (in feet/inches)

Dancer's weight (in pounds)

Current therapies dancer is receiving

Physical Therapy

Occupational Therapy

Speech Therapy

Aquatic Therapy

Not currently reciting therapies

Other:

Current adaptive devices or equipment being used

Level of assistance dancer requires with everyday activities

No assistance required

Little assistance required

Moderate assistance required

Significant assistance required

Total assistance required

Clear selection

Approximate distance dancer is able to walk (please not if this is with or without assistance/equipment, or if not able to walk)

Please provide a description of the dancer's developmental/communication impairments, if any./ List any pertinent information about the dancer's ability to understand what is said to them, ability to express wants/needs, including any techniques or gestures used, etc.

List any behavioral issues that may require special techniques or intervention from staff or volunteers

Please describe any special needs the dancer might have in managing their bladder and/or bowel during dance sessions

Has the dancer had experience participating in any other sports or physical activities in the past (including any previous dance programs)? Please list these

Does the dancer participate in any other sports or physical activities currently? If so, please list these.

Please list any individual goals you would like us to focus on with your dancer

Any other relevant information you think the medical directors or dance instructors should know?

Would you and your dancer be interested in partaking in a filmed performance at the end of the session to be used for education, outreach, and community enjoyment?

Yes

Other:

Clear selection

Submit

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