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Excellent Elephants Participant Assessment Form
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* Indicates required question
Email
*
Your email
Swimmer's First & Last Name
*
Your answer
Medical Information
Diagnosis:
*
Confirmed medical diagnosis or general needs: Example Cerebral palsy, sensory aversion or Impulse control.
Your answer
Behavior Information
Aggressive behavior:
*
To self or others; typically seen when frustrated or over stimulated
Yes- Please explain in the comments section
No
Other:
Required
Communication information
Expressive:
*
Verbal
Verbal limited - Please explain in comment section
Non-Verbal
Sign language
Other:
Required
Receptive: Follows simple directions
*
Yes
No
Verbal
Written
Gestural
Other:
Required
Understanding : Uses visual schedule
*
Yes
No
Written
Picture
Object
Other:
Required
Special Interest / Favorite things
List things your child likes.
Sports, Games, Books, Toys, Music, Shopping, Positive reinforcers
Your answer
Fears and Dislikes
Let us know what your child does not like; About water or in general
Your answer
Do you have any behavioral strategies that you would like to share?
Your answer
Would you like any specific speech or communication worked on during swim lessons? If so, what specifically?
Your answer
Additional comments
Your answer
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