Skip to content
Back to School Swim Lessons
Register Now
About
FAQs
First Day
Swim-n-Tell
Meet Our Team
Join the Team
Swim Scholarship
Swim Lessons
Monthly Group Classes
Infant & Toddler Program
Three’s Program
Preschool Program
School Age Program
Adaptive Aquatics
Private Swim Lessons
Kathryn
Water Safety
Parent Portal
Contact us today!
Menu Toggle
About
Menu Toggle
FAQs
First Day
Swim-n-Tell
Meet Our Team
Join the Team
Swim Scholarship
Swim Lessons
Menu Toggle
Monthly Group Classes
Menu Toggle
Infant & Toddler Program
Three’s Program
Preschool Program
School Age Program
Adaptive Aquatics
Private Swim Lessons
Menu Toggle
Kathryn
Water Safety
Parent Portal
SNAP Questionnaire
1
Page 1
2
Page 2
3
Page 3
Email
*
Parent Name
*
Phone
*
Swimmer's Name
*
First
Last
Swimmers date of birth
*
Diagnosis
Has your swimmer participated in aquatics at another facility?
Select One
Yes
No
Maybe
History of previous swim experience:
List known swim skills:
Please describe your swimmer's previous experience with water.
Are they fearful?
Select One
Yes
No
Maybe
How does your child best learn?
Select One
Auditory
Visual
Kinestetic
What situations, events, and/or types of stimuli could cause your child to have a meltdown?
Is your child able to organize his/her behavior after a meltdown and return to task?
Select One
Yes
No
Maybe
Parent's Goals & Objectives
Water Safe
Comfort in Water
Basic Swim Skills
Endurance
Strength
Motor Skill Development
Advance Swim Skills
Other
Please elaborate
Medical Diagnosis
Physical Restrictions
Seizure disorder
Yes
No
Mobility
Ambulatory with device
Wheelchair
Independent
How will swimmer enter pool
Independent via steps
With assistance from another person
Chair lift
Other
Please elaborate
Does swimmer have difficulty with (check all that apply)
Gait
Strength
Balance
Endurance
Coordination
Range of Motion
Not Applicable
Vision
Normal
Can see light/ shadows
Legally blind
Hearing
Normal
Mild loss
Mod/ severe loss
Deaf
Speech/ Communication
Verbal
Non-Verbal
Sign
Other
Please elaborate
Cognitive
Short attention span
Requires verbal cues to complete task
Follows directions well
Impulsive
Easily Distracted
Does your swimmer participate in therapies (ie: PT/ OT/ Speech)?
Physical Therapy
Occupational Therapy
Speech Therapy
ABA
Other
Please elaborate
I understand that a medical release may be required for my child to participate in swim lessons.
*
Yes
No
CAPTCHA
Scroll to Top
