CAPA (Fall 2022) Participant Information Form

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The aim of our program is to develop the physical, social, and cognitive skills of
the participants. The student volunteers will work one-on-one with a specific
participant to develop a long-term plan to help them work toward specific goals in
a fun and interactive setting. Therefore we ask you to complete the following form
to help identify areas of special need, including any goals you may have for your
child.

Email *

Semester of Registration *

Fall (September-December) 2023

Required

Name of Participant *

Participant's Date of Birth *

YYYY

Parent/Guardian Name(s) *

Parent/Guardian Phone Number(s) *

Parent/Guardian Email(s) *

What is you Home Address? *

What type of disability does your child experience? *

Please describe any physical goals you may have for your child, including fundamentals of movement (running, jumping, throwing, catching, etc.) and sport-based play (soccer, basketball, swimming, etc.), as well as their current ability level in related goals: *

Please describe your child’s current comfort level with pool activities. If applicable, please indicate their current swimming level. *

NkekskskPlease describe any social goals you may have for your child. Please describe to us what type(s) of communication and instruction your child best works with. Please let us know if there are any specific adaptations or modifications that your child/athlete has benefited from in the past or you would like to recommend to us. Examples may include instructions if your child is non-verbal, prefers visual cues, schedules, sequencing instructions, etc. *

Please describe any cognitive goals you may have for your child (sounds, colours, shapes, reading, writing, etc.), as well as their current limitations: *

Please describe any activities you believe your child would benefit from or truly enjoy: *

Please let us know if there is anything else you would like us to know about your child (physically, emotionally, socially, etc.) related to their safety and comfort, that would help make their experience with our program a positive one. *

Please describe what type of physical environment your child performs best in. Please let us know if there are any adaptations or modifications that your child/athlete has benefited from in the past or you would recommend to us that would help make your child’s experience successful. *

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