Learn to Swim Pre-assessment Form

LEARN TO SWIM PRE-ASSESSMENT

To ensure we understand your child's level of swimming ability, please fill out the form below. Once completed, this form will be sent to the AUT Millennium School Programme staff.
Student Details
Name

First NameLast Name
D.O.B

MonthDayYear
School Name*
Classroom number eg Class 2
Year Level
Swimming Ability
I have had swimming lessons previously

YesNo
I can fully submerge my head under water

YesNo
I am confident (can select more than one)

Floating on my front or back in a starfishKicking on my front with a boardKicking on my back with a board
Freestyle

I cannot swim with freestyle arm circlesI can swim >5m freestyle arm circlesI can swim 15m with breathing to the sideI can swim 25m with breathing positionI can swim 50m with breathing positionI can swim 100m with breathing position
Backstroke

I cannot swim with backstroke arm circlesI can swim >5m backstroke arm circlesI can swim 15m backstroke arm circlesI can swim 25m backstroke arm circlesI can swim 50m backstroke arm circlesI can swim 100m backstroke arm circles
Breaststroke

I cannot demonstrate breaststroke kickI can demonstrate breaststroke kick
Health Assessment
Are there any medical conditions or learning needs we need to be aware of?

YesNo
If you selected "Yes" to the above, what medical conditions or learning needs do we need to be aware of?
Thank you for taking the time to complete this form.
Should be Empty:

LEARN TO SWIM PRE-ASSESSMENT