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Special Needs Adaptive Aquatic Programs
Preparation is often the key to success. Please complete the following to help us provide the needed support and strategies appropriate for your child.
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* Indicates required question
Child's Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Parent's Name
*
Your answer
Best Contact Telephone
*
Your answer
Email Address
*
Your answer
Preferred method of contact
*
Email
Phone
Text
Diagnosis
*
Your answer
Active Therapies
*
Physical Therapy
Occupational Therapy
ABA
Speech Therapy
Recreation Therapy
Other:
Required
Vision
*
Normal
Can see light/ shadows
Legally Blind
Hearing
*
Normal
Mild Loss
Severe Loss
Deaf
Speech
*
Verbal
Non-Verbal
Sign
My child learns best in small groups
*
Yes
No
Other:
My child learns best with one-on-one instruction
*
Yes
No
My child is
*
Hypoactive
Hyperactive
A schedule, such as PEC board, can help with transitions
*
Yes
No
Unsure/ Maybe
My child does not like to be touched
*
Yes
No
Other:
My child is able to organize his/ her behavior after a melt down and return to task.
*
Yes
No
Other:
Loud noises and/ or visual distractions bother my child.
*
Yes
No
Other:
Potential triggers for a melt down are
*
Your answer
Parent/ Caregiver's goals for program participation
*
Water Safety
Comfort in Water
Motor Skill Development
Strength
Endurance
Basic Swim Skills
Other:
Required
Please let us know your availability for programs:
*
Your answer
Please feel free to include any other information you feel may be helpful in working with you and your child.
Your answer
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