SLCo Adaptive Aquatics Intake Form

Adaptive Aquatics Intake Form
Salt Lake County Parks & Recreation offers various inclusion and specialized recreation options for swimmers with disabilties. This is an optional form, but highly encouraged as it provides additional information on your swimmer that will help our instructors best meet their needs!
Participant Information
Participant's Name*

First NameLast Name
Age
Gender

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Best Phone Number*

Area CodePhone Number
Alternative Phone Number

Area CodePhone Number
E-mail*
Program Type
Adaptive Aquatics: Our adaptive aquatics programs are specialized for just individuals with disabilities. Our adaptive programs include:
- Otters: group swim lessons for children and teens ages 3-18. Lessons run in a 3:1 student to teacher ratio.
- Adaptive Swim Club (ASC): swim team for individuals ages 15+. Lessons run in a 6:1 student to teacher ratio.
- Private Swim Lessons: one on one lessons with an instructor.
Inclusion Aquatics: Our inclusion services are designed to provide additional support for individuals with disabilities wanting to participate in mainstream aquatics programming.
Please select which program you are most interested in:

Otters Group LessonsAdaptive Swim ClubPrivate Swim LessonsInclusion
Select your preferred pools. Not all pools currently offer all adaptive programming. We will find a program closest to you that will fit your needs.

Holladay Lions (Holladay)Gene Fullmer (West Jordan)Northwest (SLC)Steiner West (SLC)Sports Complex (SLC)Fairmont (SLC)Dimple Dell (Sandy)South Jordan (South Jordan)Draper (Draper)JL Sorenson (Herriman)
Tell Us About The Swimmer!
Swim Abilities/Goals
Has the participant ever been in a swimming program before? If so, please indicate the type/level of the program:
Check all that apply:

Is afraid to go under waterCan float independentlyCan hold breath underwaterCan swim the length of the pool

What are your primary goals for enrolling in the program? (please rate 1, 2, 3, etc.)

	1	2	3	4	5	6	7
Recreation Participation (exposure to a variety of activities)
Recreation activity skill enhancement
Opportunities to experience fun in play
Socialization
Physical fitness/wellness
Improve group participation and social skills
Other

OTHER Goal:
Primary Disability
What is the swimmer's primary disability? Please include any relevant information including asthma, allergies, seizures, diabetes, and any intellectual and/or physical disabilities.
Are there steps you take with regards to the above listed health issues that we need to be aware of such as what to do for seizure, low blood sugar, allergies, etc.
Social & Communicaiton Skills

This Section Required*

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Comprehends and learns through verbal directions
Consistently requires visual aids and modeling to participate in activities
Speaks and is clearly understood
Uses sign language
Is sensitive to loud noises
Initiates conversation and/or seeks contact with peers
Can manage his/her anger when upset
Communicates personal needs
Routines are important
Transitions are difficult
Cooperates with staff and peers; shares
Stays with assigned group with minimal supervision
Becomes frustrated during recreation activities
Avoids or is hesitant about decision making
Maintains personal space
Can stay on task for 20+ minutes

Are there any behavioral concerns or triggers that we should be aware of?
What strategies/techniques are used at home/school/work to promote positive behavior and/or discourage or redirect inappropriate behavior? Does the participant use a specific behavior plan? (If yes, please provide a copy of the plan.)
What are some of the participant's strengths?
What are some topics of personal interest to the participant?
Is the participant able to use the restroom on their own?*

YesNo
If you answered "No", please note that TWO layers of swim diaper are required in the pool: the swim diaper itself and the plastic covering. Salt Lake County pools sell both of these items in children's sizes.
Under the ADA (Americans with Disabilities Act) you are entitled to reasonable accommodations as a participant with a disability. What specific ADA accommodations are you requesting?
Please use this space to provide any other information that is important to know about the participant:
Thank You!
If you are participanting in inclusion services your profile form will be passed on to the coordinator overseeing the aquatics program at the rec center you indicated above.

If you are participating in adaptive services one of our adaptive staff will be in touch to set up an In-Water Assessment. This is a 15 minute assessment to better understand the needs of the participant and recommend appropriate program placement.
To contact an Adaptive Aquatics Staff please email adaptiveaquatics@saltlakecounty.gov
Should be Empty:

Adaptive Aquatics Intake Form

Thank You!