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
Does the participant identify as having a disability or developmental delay such as:
Speech

HearingPhysicalVisionSpeechIntellectualMobilityOther
Please indicate any further details
MEDICAL CONDITIONS
Does your child have Epilepsy?

YesNo
Any recent seizure activity? If Yes please submit your seizure management plan.

YesNo
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.

Clear
Does your child have any Allergies?

YesNo
Please indicate any further details
Does your child use an Epipen for Anaphylaxis? If Yes please submit your Anaphylaxis management plan.

YesNo
Does your child have Asthma? If Yes please submit your Asthma management plan.

YesNo
Does your child need to take medication during the session?

YesNo
Has your child had an operation or serious illness in the last 6 months?

YesNo
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?

YesNo
When it comes to swimming are they;

Very competent in deep waterCan swim unaided with a floatation deviceRequires assistance in the waterRequires more than one assistant for supportDoes not like swimmingOther
Are they able to swim Freestyle?

YesNo
Distance Freestyle?
Are they able to swim Dog Paddle?

YesNo
Distance Dog Paddle?
Can they put their face in the water?

YesNo
Can they hold their breath underwater for 5-10 seconds?

YesNo
Can they tread water / float for more than 1 minute?

YesNo
Does your child utilise a flotation device?

YesNo
Type of flotation device
Has your child ever been swimming in the ocean?

NeverA few timesRegularly
Any relevant further details e.g. how did they find the experience
Have you attended another club's additional needs Nippers programme?

YesNo
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

Communicate verballyUnderstands simple 1- 2 step verbal instructionsMakes eye contactUnderstand non-verbal communication (E.g. hand gestures)
Does your child require communication aids?

YesNo
If yes, please state type

Key Word SignVisualsAuslanSocial StoriesAAC DeviceOther
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?

YesNo
If yes, please specify type of assistance required
Does your child require use of a wheelchair?

YesNo
Does your child enjoy being

Very ActiveActiveQuietOther
SENSORY
Does your child have sensory support needs?

YesNo
If Yes, please specify
Does your child run away?

YesNo
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?

YesNoOther
Signature of parent / Guardian

Clear
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

Clear
Date

MonthDayYear
Date
I have read and understood my obligation of providing the Club with seizure, anaphylaxis and asthma management plans.

YesNo
I have read and understood my obligation to inform the club of any seizure activity with 24 hours prior to a Nippers session.

I have provided a copy of my child's current seizure/Epilepsy management plan.I have provided a copy of my child's current Asthma management plan:I have provided a copy of my child's current Anaphylaxis plan:
Signature of parent / Guardian

Clear
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

Clear
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