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CRIL 2023-2024 Program Registration
When applicable, when entering your name into the google form you are consenting to electronic signature.
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Email
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Record my email address with my response
Participant Name:
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Your answer
Participant nickname/preferred name
Your answer
T-Shirt size (adult sizes)
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XS
S
M
L
XL
XXL
3XL
Birthdate:
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MM
/
DD
/
YYYY
Gender
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Male
Female
Prefer not to say
Other:
Where does your child attend school and what grade are they enrolled for the 2023-2024 school year?
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Your answer
Your child has an...
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IEP
BIP
None
Required
Please check all that apply:
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ADD/ADHD
Autism/ASD
Brain Injury
Cerebral Palsy
Down Syndrome
Emotional Disturbance
Intellectual Disability
Learning Disability
Multiple Sclerosis
Muscular Dystrophy
Physical Impairment
Speech Impairment
Spina Bifida
Other
Required
Please provide additional/specific details on your child's diagnosis:
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Your answer
Describe your child's social/emotional abilities and needs:
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Your answer
Please check all that best describe your child's physical abilities and needs:
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Walks without assistance
Walks with a cane and/or walker
Uses a wheelchair
Other
Required
Please check all that best describe your child's visual abilities and needs:
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Wears glasses and/or contacts
Peripheral vision deficits
Central vision deficits
Other
None
Required
Please check all that best describe your child's hearing abilities and needs:
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Hard of hearing
Deaf
Uses hearing aids
Has a cochlear implant
Other
None
Required
Please check all that best describe your child's communication abilities and needs:
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Verbal
Non-Verbal
Speech Delay
Speech Impediment
Uses communication device
Uses sign language
Other
Required
What are signs that your child is upset?
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Your answer
What can we do to help your child cope/calm down when they are upset?
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Your answer
What situations are stressors or triggers for your child?
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Your answer
What does your child like?
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Your answer
What does your child dislike?
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Your answer
What are your child's favorite activities?
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Your answer
What are your child's least favorite activities?
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Your answer
What does your child struggle with?
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Your answer
Please describe any behavioral concerns we should be aware of:
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Your answer
List any equipment the participant uses (for example, walker, hearing aids, glasses, etc.) for activities of daily living:
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Your answer
Does the participant have any specific head impact precautions; shunt location, atlantoaxial instability, etc. If yes, please describe:
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Your answer
Does the participant experience seizures? If "no" is selected, please skip the following 2 questions.
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Yes
No
Please describe the type and frequency of seizures:
Your answer
How are seizures treated for the participant? (Let it runs its course, meds, and/or ambulance, etc).
Your answer
Which best describes your child in the pool?
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My child does not get in the pool
Cannot swim, holds on to wall or another person, does not go under water, keeps feet on ground
Can swim, but is a weak swimmer
Can swim, but is a strong swimmer
Does your child wear a life jacket or flotation device?
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Yes, my child needs to wear a life jacket
No, my child does not need to wear a life jacket
Is there anything that staff should know regarding your child in the water?
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Your answer
Please list any other information the programs leaders should know: (friends, people they do not get along with, habits, things we should be aware of, etc.)
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Your answer
Please list 3 goals you have for your child this year:
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Your answer
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