Special Needs Parent and Family Form
At Katie's Kickers, our goal is to meet all our swimmers where they are at and equip them with skills to improve their health, safety, and ability in the water. The information you provide here will be used to help develop individualized and meaningful activities to affirm and strengthen individuals’ unique interests, strengths, and goals. The information provided below is confidential and once received, we will reach out to you and set up a time you can come visit our location prior to your first lesson. Thank you!
Parent's Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Preferred method of Contact
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Email
Phone
Child's Name
*
First Name
Last Name
Child's Age
*
-
Month
-
Day
Year
Date
Is your child toilet trained?
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Yes
No
Does your child have a history of seizures?
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Yes
No
Do you wish to share your child's academic or medical diagnosis? Are they in any active therapies that would help us best understand their needs? If so, please explain.
My child's strengths, interests, and/or favorite activities are:
How comfortable is your child in the water? Does your child like the water or do they try to avoid the water?
What is your overall goal with swim lessons for your child?
When introduced to new situations and surroundings, what has been successful in easing your child's anxieties?
Please share how your child prefers to communicate:
The following makes my child upset/agitated:
When my child is happy, excited, and/or motivated they indicate their feelings by:
When my child is sad, angry, and/or agitated they indicate their feelings by:
What are some common tactics you use with your child to soothe them when agitated and/or over excited?
What motivates your swimmer, particularly when it comes to doing the things they prefer not to do?
What could be good motivators or reinforcements for positive behavior at the pool?
Does your child use a visual schedule and/or visual cues at home, school, etc.?
Do you feel your child would make safe choices in a small group class of 3 swimmers (being a good listener, staying on the wall when asked, waiting their turn, keeping their head above the water, etc.) or would a private/semi-private class be more suitable?
Please feel free to include any other information you feel may be helpful in working with you and your child.
Please share any questions you have for our team.
Have you already registered for a class? If so, which one?
Preferred lesson times and availability?
Would you like us to contact you to visit the facility prior to your first lesson?
Submit
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