Adaptive Swimming Participation Form

Participant Information

Please provide the following information so that we can plan the appropriate care and participation level for your child.
Participant's Name*

First NameLast Name
Participant's Date of Birth*

MonthDayYear
Date
Parent/Guardian's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Adaptive Swim Practices will help athletes learn and build upon their swimming skills. This program will be led by a coach with the help of volunteers. Our mission is to encourage, help, build and strengthen healthy physical activity, confidence, social skills and more.

Space is limited; Registration is required.

Thank you for participating in our adaptive swimming programming. We look forward to you being here with us.
Choose a level that best describes the participant's swimming ability*

Loves the water, looking to improve upon skillsApprehensive about getting in water, has basic skillsFears the water, needs assistance getting acclimated
What is your Membership status?*

MemberNon-member
If there are any additional family members that will attend the events with the participants, please list each of their full name(s) and date(s) of birth.
List Full Name and Date of Birth
Please describe the participant's level of communication? How does the participant communicate with others? *
Has the participant previously been in any social skills groups, played sports, therapy, etc.?*

YesNo
If yes, please provide a short summary. How did the participant relate with peers?
Please detail any current health concerns, allergies, conditions, side effects from medications:*
Please detail any current problem behaviors the participant may engage in. How often do they occur? How intensive are they? Are there any known triggers we should take note of? *
Any gross motor limitations?*

YesNo
If yes, please explain:
Does the participant like music and dancing?*

YesNo
Any sensory issues (ex. sensitivities to light, sound, smell, touch)? *
Does the participant have issues transitioning from one activity to another?*

YesNo
If yes, please explain:
Are there any other concerns we should be made aware of?
List Emergency Contact*

First NameLast Name
List Emergency Phone *
Please enter a valid phone number.
Signature

Clear
Signature Date*

MonthDayYear
Date
Should be Empty:

Participant Information