Special Abilities Intake Form

Special Abilities Intake Form

Please fill out this form to the best of your abilities so that we can better assist your student with special abilities in their lessons.
Uplifter Member Account*

First Name Last Name
E-mail*
example@example.com
Phone Number*
Student Name*

First Name Last Name
Student Birth Date*

Month Day Year
Student Gender
Has you student swam with us before?*

YesNo
What is your student's specific diagnosis?*
Does your student require assistance with any of the following? Check all that apply.*

WalkingParticipating in/remaining with a groupWaiting their turnGrasping/manipulating objectsToiletingListening/following directionsNoneOther
If other was selected, please describe.
How does your student communicate?*

VerbalNonverbal
If your student is nonverbal, what forms of communication are used?
Please describe any medical needs or allergies that we should know about.*
Describe any special accomodations necessary for physical disabilities.*
Describe any specific behaviour(s) your student has that we should be aware of prior to their lessons. *
How does your student handle transitions? For example, between activities.*
Has your student participated in any other recreational activities? If yes, please describe their experience.*
Describe your student's personality.*
Please feel free to share any additional information about your student and how we can best assist them here.
Should be Empty: