Special Needs Information Form
Welcome! Our mission is to allow children with special needs to have fun while acquiring water safety and basic swimming skills. The following questions will help us lead your child to swimming success!
See additional information about pricing and guidelines on our website https://www.hubbardswim.com/privatelessons
PLEASE NOTE as of June 2021 we are on a waitlist for all Special Needs classes.
Submitted forms will be contacted when we have a class available.
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ENROLLMENT REQUEST
Below please select the location you are interested in. Then check the time slots you are available to attend. Our Enrollment Coordinator will alert you of availability to start this week or if classes are full add you to our waitlist to monitor for future availability.
Swim Location
*
Please Select
Phoenix (32nd St & Thunderbird)
Peoria (84th Ave & Thunderbird)
Riverview (202 & Dobson Rd)
Goodyear (Pebble Creek Pkwy & McDowell)
Offered Friday afternoon 3:00 - 6:00p. Please select times you are available.
*
3:00
3:30
4:00
4:30
5:00
5:30
6:00
Offered Friday afternoons 3:30 - 6:30p. Please select times you are available.
*
3:30
4:00
4:30
5:00
5:30
6:00
6:30
Goodyear - Please tell us days and times you are available to attend weekly.
*
I currently have an account at the location I listed above to process my request and allow future communication by email.
*
YES!
No, but I will within 1 hour of submitting this request. I understand my enrollment request will become inactive if I do not have an account created. https://www.hubbardswim.com/register
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SWIMMER'S BASIC INFO
Swimmer's Name
*
First Name
Last Name
Gender
*
Please Select
Female
Male
Current Age
*
Available for children 3 up to 12 years old
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MEDICAL INFORMATION
Social / Developmental Age
*
Is your child toilet trained?
*
Yes
No- we require a reusable cloth swim diaper
On location up to a 4T is available to purchase. 5T and larger swim briefs can be purchased at www.theraquatics.com
Does your child aspirate
*
Yes
No
Is your child on thickened liquids?
*
Yes
No
Diagnosis Information
*
Any physical limitations we should be aware of?
*
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BEHAVIORAL INFORMATION
Does your child have aggressive behavior?
*
Yes
No
Communication
*
Verbal
Limited Verbal
Non-Verbal
Sign-Language
Speech Device
Other - please detail below
Additional Behavioral or Communication Information
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CHILD INFORMATION
Special interests or favorite things?
*
Fears or dislikes?
*
Positive Reinforcement Techniques
*
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SWIM EXPERIENCE
What is your child's past experience in the water?
*
What goals do you have for your child in this program? Anything else you would like us to know about your child?
*
Submit
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