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 once we have a class available.
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ENROLLMENT REQUEST
Please choose your preferred location and check the time slots your swimmer can consistently attend throughout the year. Since our waitlist is long and timing is unpredictable, we ask that availability reflects all seasons.
Swim Location
*
Please Select
Phoenix (32nd St & Thunderbird)
Peoria (84th Ave & Thunderbird)
Riverview (202 & Dobson Rd)
Goodyear (Pebble Creek Pkwy & McDowell)
Offered Friday afternoons from 3:00 - 6:00p. Please select times you are available.
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3:00
3:30
4:00
4:30
5:00
5:30
6:00
Offered Friday afternoons from 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 can offer Special Needs classes during the week before 2:00 pm at our Phoenix location. Please select the days you would be available. If we have a class open, we will contact you.
Monday 9:00am-1:00pm
Tuesday 9:00am-1:30pm
Wednesday 9:00am-1:00pm
Thursday 9:00am-1:30pm
Friday 9:00am-11:30am
On rare occasions, we can offer Special Needs classes during the week before 2:00 pm at our Peoria location. Please select the days you would be available. If we have a class open, we will contact you.
Tuesday 9:00am-1:30pm
Wednesday 9:00am-1:30pm
Thursday 9:00am-12:00pm
On rare occasions, we can offer Special Needs classes during the week before 2:00 pm at our Riverview location. Please select the days you would be available. If we have a class open, we will contact you.
Wednesday 9:00am-12:00pm
Thursday 9:00am-12:00pm
On rare occasions, we can offer Special Needs classes during the week before 1:30 pm at our Goodyear location. Please select the days you would be available. If we have a class open, we will contact you.
Monday 9:00am-1:30pm
Tuesday 9:00am-1:30pm
Wednesday 9:00am-11:30am
Thursday 9:00am-11:30am
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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 through 11 years old
Primary 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
*
Are there any physical limitations we should be aware of?
*
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COMMUNICATION INFORMATION
Communication
*
Verbal
Limited Verbal
Non-Verbal
Sign-Language
Speech Device
Other - please detail below
Additional communication information.
*
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BEHAVIORAL INFORMATION
Does your child have aggressive behavior? Ex: Biting, pinching, hitting, etc.
*
Yes
No
Please elaborate on your child's behavioral needs. This will help us find the best match for your child.
*
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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 experience in the water?
*
What goals do you have for your child in this program? Is there 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 text and email you when a class becomes available.
*
Yes. I am interested in being contacted when a class is available based on my availability summited.
If I am no longer interested in the waitlist or my availability changes I will contact SpecialNeeds@hubbardswim.com with this information.
We are unable to offer makeups to swimmers who have special accommodations in place because we cannot replicate those specific accommodations.
*
Yes. I understand my swimmer will not be eligible for makeup lessons or financial credit if I am unable to attend my lesson. Ex: Vacations, illness, scheduling conflict, etc.
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Submit
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