Flip Turn Adaptive Swim Intake Form
Please fill out this form so that we can better understand and serve you child's unique needs.
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Email *
Swimmer Name: *
Birth Date: *
MM
/
DD
/
YYYY
Parent / Guardian Name: *
Home Address
Contact Phone: 
Text messages may be sent to the phone number provided as a convenient way to notify you of any schedule changes or emergencies.
 *
Which Regional Center are you receiving resources/services from? *
Required
Service Coordinator Name: *
What services are you receiving now, if any? (Speech, OT, etc.)
How are your services funded?
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Are you set up Self-Determination Program (SDP) at your Regional Center?
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If YES you're already set up with SDP, 
are you working with an Independent Facillitator? 
( If Yes, please provide name and contact. )
If NO you're not set up with SDP or any Regional Center,
would you like help getting set up?
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Please select your preferred time window(s) for swim lessons: 
Morning: (9:30am - 1:00pm) 
Afternoon: (1:00pm - 4:00pm)
Saturday: (12-1) Currently Waitlisted
**day/time based on availability**
 *
Required
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