Let’s FlOaT Information (THIS WAIVER IS ONLY FOR OUR ADAPTIVE SWIMMING PROGRAM) and Consent Form 1 of 2 Wavier Forms

Haley’s Little Fish Let’s FlOaT *******this waiver form is only for our Let’s FlOaT program****** if your child is not enrolled in this specific class please fill out the other form

Information and Consent Form. Please make sure you fill out both wavier forms.
Your Name

First NameLast Name
Child’s Name*

First NameLast Name
Child’s age *
Phone Number*

Area CodePhone Number
Email
example@example.com
Lesson Days*
Your Instructor *
I’d like to add a Haley’s Little Fish T-shirt for my child for $20.00, if so please leave your child’s size *
I’d like to add a wet bag for my child’s lessons for $15.00*
Wet bag will be at the pool when ready for pick up.
How did you hear about us?*
Has your child attended any type of swim lesson before?*

YesNo
If yes, what type of lessons?*
I understand that Haley’s Little Fish allows ONE unexcused absence with eligibility for a makeup lesson as long as a minimum of a THEEE hour notice is given*
At Haley’s Little Fish, the health and safety of your child is our first priority. Our ability to keep our pool open is dependent on parental responsibility and adherence to policies to ensure that our pool remains clean. A $250 pool contamination fee will be charged in the event of POOL CLOSURE*
I understand that my child should not eat or drink anything other than WATER 2.5 hours before lessons *
I understand that I WILL NOT allow my child to eat fruit, vegetables, meat or dairy products FOUR hours before lessons. This includes milk, formula, yogurt and cheese.*
I understand that if my child causes a pool contamination of any sort, I will be charged a $50.00 clean up and chemical fee*
If my child is THREE years old and younger, I understand that I have to DOUBLE swim diaper, my child. (Two REUSABLE swim diapers) If an accident occurs in the pool, I understand that I will be charged $250 for cleanup fees. If I do not have an appropriate diaper on my child, I understand that I am forfeiting that days lesson. *
We have provided links on our website
I recognize and acknowledge that I am enrolling my child in survival swim lessons and will not hold Haley’s Little Fish or the instructor teaching my child liable for any accident that may occur in or around the pool area. *
I understand that there are NO refunds given and no lesson credit transfers. All makeup lessons must be used within 14 days without a doctors note and 30 days with a doctors note. *
I understand that if I am more than five minutes late for my lesson, I am for forfeiting that lesson. *
Haley’s Little Fish suggests that all students enrolled in lessons should be covered by their own family insurance policies. If injury should occur it is understood that the student’s own policy is your only source for reimbursement. *
I understand that no child is “drown-proof” and should watch my child at all times around any body of water *
What do you want your child to gain from these lessons?*
I understand that it is my responsibility to notify my instructor of any and all medical history changes or health concerns*
Does your child have any medical history we should know about? *
Is there any additional information we should know about your child?*
Let's FlOaT

Adaptive Swim Lesson questions **If these lessons do not apply to you, please type N/A in each box.
Does your child have a medical diagnosis? If yes, please add. *
Ex. ASD, CP, Muscular Dystrophy, etc.
Does your child have auditory processing concerns?

yesnoYes, and my child uses a communication device
Does your child have a history of seizures? If yes, please describe frequency. *
Does your child have a G-tube? If yes, please cap the tube prior to water submersion.

Yes, my child has a G-Tube, and I will cap.No, my child does not have a G- tube.
Does your child have any sensory hypersensitivities? Please select all that apply, and describe in "other" box.*

Sensitive to lightSensitive to touchSensitive to soundSensitive to movement (doesn't like to be flipped, spun, jumping, etc.)My child does not have sensory sensitivitiesOther
Does your child have hyper/hypotonia issues? If yes, please describe muscle tone issues and location. If not, type N/A. *
Has your child received medical clearance to engage in underwater activity? CONTRAINDICATIONS: CHF, pulmonary edema, tracheostomy, open wounds, infectious disease. *
Type "yes" if your child is medical clear to engage in swim lessons.
I understand that my swim instructor is NOT providing OT services, but simply using her OT skills to add to my child's lesson. I understand that my insurance will not be billed for swim lessons. Type "yes".*
Signature*
Thank you for filling this form out. We are excited to meet you and your little one! Make sure to follow us on Facebook and Instagram for updates and news.
Should be Empty:

Haley’s Little Fish Let’s FlOaT *******this waiver form is only for our Let’s FlOaT program****** if your child is not enrolled in this specific class please fill out the other form

Let's FlOaT

Haley’s Little Fish Let’s FlOaT *this waiver form is only for our Let’s FlOaT program if your child is not enrolled in this specific class please fill out the other form