Special Needs Intake Form
Welcome! Our mission is to allow children 3-11 years old 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
All Special Needs classes are currently on a waitlist.
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
I currently have an account with my student listed 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 with my student listed. https://www.hubbardswim.com/register
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On rare occasions, we are able to offer Special Needs classes during the week before 2:00 pm. Please select the days you would be available. If we have a class open we will contact you.
Monday AM
Tuesday AM
Wednesday AM
Thursday AM
Friday AM
On rare occasions, we are able to offer Special Needs classes during the week before 2:00 pm. Please select the days you would be available. If we have a class open we will contact you.
Tuesday AM
Wednesday AM
Thursday AM
On rare occasions, we are able to offer Special Needs classes during the week before 2:00 pm. Please select the days you would be available. If we have a class open we will contact you.
Wednesday AM
Thursday AM
On rare occasions, we are able to offer Special Needs classes during the week before 2:00 pm. Please select the days you would be available. If we have a class open we will contact you.
Monday AM
Tuesday AM
Wednesday AM
Thursday AM
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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
Preferred Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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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?
*
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PLEASE NOTE
HFSS is on a waitlist for all Special Needs classes. We will contact you when we have a class available.
*
Yes. I am interested in being contacted when a class is available based on my availability summited.
We are unable to offer makeups to swimmers who have special accommodations in place due to our inability to replicate those specific accommodations.
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Yes. I understand my swimmer will not be eligible for makeup lessons or financial credit if I miss my class.
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