New Student Dance Abilities Registration Form
We are thrilled that you have an interest in Project 16 - Dance Abilities Program! Please take some time to fill out this form - the more details the better. We want to make sure we have as much information as possible to better understand the student's needs so that we can make this dance/movement program a rewarding experience for everyone involved! If you have any questions or concerns please don't hesitate to reach out to us at projectmllc24@gmail.com. Thank you!
Customer Details:
Parent/Guardian Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Contact
First Name
Last Name
Emergency Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Student Full Name
*
First Name
Last Name
Student Birthdate
-
Month
-
Day
Year
Date
Student Diagnosis: Explain any details that will help us better understand the student and their needs.
Does the student have any allergies? If so is the student on medication for allergies?
Does the student have any sensitivities? If so, please explain.
Are there any precautions we should take in working with the student? (i.e. seizures, biting, etc.) If so, please explain.
Does the Student have siblings? If yes, names and ages.
Dance Experience and Interest
Has the student partaken in an adapted dance lessons before? If so, please tell us where and the overall experience.
Has the student ever had any other dance experience? Studio run dance classes, Recreational Center dance classes, etc.
Please list the student's favorite style of music. Favorite artists, songs...
Fine & Gross Motor Skills
Have you noticed that the student has had any gross motor difficulties? If so, please define.
Is the student fully ambulatory? If not, please define.
Does the student require physical assistance? If so, please define.
Does the student have full use of limbs? If not, please define.
Has the student been diagnosed with high/low muscle tone? If so, please define.
Communication Skills
Does the student communicate verbally?
yes
no
If the student does not communicate verbally, what is the functional form of communication used at home and school?
iPad/Communication Device
Sign Language
PECS - Picture Exchange System
Other: __________________________________________________________________________
Has the student been diagnosed with any hearing difficulties? If so, please explain.
Does the student have difficulty hearing sounds or understanding speech? Of so, please define.
Does the student understand or react to what is bing said to him/her?
yes
no
If the above answer is NO, please explain.
Emotional Regulation Skills
Does the student display emotions appropriately?
yes
no
Does the student act our, tantrum, or get angry easily?
yes
no
If YES to the above, what are the triggers usually associated with the above behavior?
Does the student display any abnormal fears or anxieties? If so, please describe.
Social Skills
Have you noticed that the student has any social difficulties? If so, please explain.
Does the student interact with peers?
Does the student have a social group or age-like peers?
yes
no
Does the student participate with conversation and play with others? If not, please define.
Does the student participate appropriately in group activities? If not, please explain.
Does the student have any particular difficulty in school or other social situations? If so, please explain.
Has the student been involved in any therapeutic social skills groups? If so, please describe the experience.
Please describe the student's social skills with family members.
Does the student interact well in a one-on-one instructed situation? If not, please explain.
Does the student have a special skills or interests? (baseball, basketball, swimming, specific toys, hobbies, like or fear of animal, etc.) Please give as much information as possible.
Sensory Needs & Sensitivities
Does the student have any sensitivities to or extreme preference for particular sounds? If so, please define.
Is the student over-stimulated by sounds, lights, mirrors or crowds. Please explain all that apply.
Does the student have any sensory processing issues? (please check all that apply)
Tactile defensiveness/seeking (touching)
Vestibular dysfunction (awareness of body space)
Proprioceptive dysfunction (planning and maintaining movement)
Auditory sensitivity/lack in sensitivity (sound)
N/A
Other: _________________________________________________________________________
Is there something not listed above that the student has issues with?
Does the student resist physical support? If so, please explain.
Additional Comments or Concerns
Is there anything else you would like to share to help us better understand the student?
What are your expectations and goals regarding this dance program?
Are there additional concerns you have regarding this program?
Thank you!
Thank you for completing this Registration Form. Your attention to this detailed information will help us get to know the student better. We will contact within 72 hours to discuss next steps.
Signature
3731 Stonegate Drive Medina, OH 44256 projectmllc24@gmail.com
Continue
Continue
Should be Empty: