STINGRAY NIPPERS participant enrolment form

STINGRAY NIPPERS
PARTICIPANT DETAILS
Name

First NameSurname
Address
Date of Birth

MonthDayYear
Date
Shirt Size
Parent/Carer Name
Email
example@example.com
Mobile Number
Format: (000) 000-0000.
Does the participant identify as having a disability or developmental delay such as:
Speech

Other
Please indicate any further details
MEDICAL CONDITIONS
Does your child have Epilepsy?
Any recent seizure activity? If Yes please submit your seizure management plan.
Please note that if your child has had seizure activity in the 24 hours leading up to a Nippers session you are required to inform of this activity. A child is unable to enter the water within 24 hours following seizure activity due to the high potential of further seizure activity and drowning.
I have read and understood my obligation to notify the Club of any seizure activity within 24 hours of a session.
Does your child have any Allergies?
Please indicate any further details
Does your child use an Epipen for Anaphylaxis? If Yes please submit your Anaphylaxis management plan.
Does your child have Asthma? If Yes please submit your Asthma management plan.
Does your child need to take medication during the session?
Has your child had an operation or serious illness in the last 6 months?
Please indicate any further details
Any other medical conditions that we need to be aware of
Please note: If answering yes to any of the above medical conditions, please attach relevant emergency medical plans.

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EXPERIENCE IN THE WATER
Has your child ever had swimming lessons?
When it comes to swimming are they;

Other
Are they able to swim Freestyle?
Distance Freestyle?
Are they able to swim Dog Paddle?
Distance Dog Paddle?
Can they put their face in the water?
Can they hold their breath underwater for 5-10 seconds?
Can they tread water / float for more than 1 minute?
Does your child utilise a flotation device?
Type of flotation device
Has your child ever been swimming in the ocean?
Any relevant further details e.g. how did they find the experience
Have you attended another club's additional needs Nippers programme?
SUPPORTS
What level and kinds of support do you feel your child needs to participate in the Nippers activities? Please indicate
COMMUNICATION
My child is able to
Does your child require communication aids?
If yes, please state type

Other
When your child is anxious, frustrated or distressed what does it look like?
What strategies are successful in calming your child in these situations? If a response plan is in place please discuss this with us so as we can best assist.
MOBILITY
Does your child require assistance to walk?
If yes, please specify type of assistance required
Does your child require use of a wheelchair?
Does your child enjoy being

Other
SENSORY
Does your child have sensory support needs?
If Yes, please specify
Does your child run away?
Please include any relevant detail
What personality traits do you like in someone supporting your child?
Anything else you would like us to know?
Do you give permission to be photographed/added to Club FaceBook page?

Other
Signature of parent / Guardian
Date

MonthDayYear
Date
Thank you for taking the time to complete this Participant Enrolment form. It will be used to both ensure that our instructors are adequately prepared and aware of what to do in case of emergency as well as to create a positive experience for your child. If you would like to add any additional information, please do so by attaching another page. We understand that the information you have provided is confidential and will be treated as such.

We ask for your permission to distribute to your allocated volunteer/instructor a collated 'All about me sheet' via email with the condition that this information is used only for the purposes of supporting your child within the Nippers program, and will not be distributed beyond these outlined parameters.
Signature of parent/Guardian
Date

MonthDayYear
Date
I have read and understood my obligation of providing the Club with seizure, anaphylaxis and asthma management plans.
I have read and understood my obligation to inform the club of any seizure activity with 24 hours prior to a Nippers session.
Signature of parent / Guardian
Date

MonthDayYear
Date
I certify that the information contained within this form is correct, and up to date. I guarantee that a parent/carer will be present at all times on the beach & available to assist as required during the Nippers sessions.
Signature of parent / Guardian
Date

MonthDayYear
Print Name
ALL ABOUT ME

This information will be collated to create a summary sheet for volunteers to support your child
Please upload a current photo of your child

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I like to be called
I am ? years old
My parent/carers/siblings names are
I have
This is how it affects me
I need this equipment/support tools (eg visuals) to access Nippers and the beach:
I communicate by (talking, gesture, visuals, KWS, AAC device etc)
I become scared/upset/frustrated/angry when:
I am sensitive to:
I am happy/motivated/focused when:
I like to be praised and rewarded by:
I like:
I DON'T like:
I really need you to know this about me:
Should be Empty:

STINGRAY NIPPERS

PARTICIPANT DETAILS

MEDICAL CONDITIONS

EXPERIENCE IN THE WATER

SUPPORTS

COMMUNICATION

MOBILITY

SENSORY

ALL ABOUT ME