PALS Questionnaire
General Information
Parent's Name
First Name
Last Name
Contact Email
example@example.com
Contact Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Name
First Name
Last Name
Child's Birthday
-
Month
-
Day
Year
Date
Sex:
Male
Female
Other
Height:
Has your child been diagnosed with Autism?
Yes
No
Is your child a sibling of an individual with Autism?
Yes
No
Does your child have any other diagnoses or support needs we should be aware of?(e.g. ADHD, anxiety, sensory processing disorder, language disorders, etc)
No
Yes
This program requires one parent/guardian/mentor per player with a diagnosis of Autism present on the pool deck for the entirety of the practice. Who will be attending?
* Age of attending adult
*Relationship of the adult to the child
1. Is your child potty trained?
Yes
No
2. How does your child feel about participating in group activities? (check those that apply)
Enjoys group activities and adapts easily
Prefers small groups but can participate in larger ones with some support
Needs a structured and predictable group setting with minimal transitions
Needs one-on-one or very small group settings to feel comfortable
3. Does your child benefit from having a designated buddy or mentor? (check one or more)
No, they are comfortable with different peers
Yes, a consistent buddy would help them feel more secure
Yes, AND their sibling is also signing up and is able to be their designated buddy
4. How does your child handle noise and busy environments?
No issues with noise or crowds or busy environments
May need occasional quiet breaks
Sensitive to noise and busy environments (requires noise-canceling headphones ordesignated quiet spaces)
5. Does your child have any sensory sensitivities related to water (e.g. water temperature,splashing, swimwear texture)? (check one)
No issues
Significant sensitivities that require specific accommodations (please describe):
5. Part 2- Does your child have any sensory sensitivities related to water (e.g. water temperature,splashing, swimwear texture)? (check one)
No issues
Some sensitivities but can adjust with guidance (please describe):
6. Is your child comfortable putting his/her face in the water?
Yes
No
Other
7. Can your child hold their breath?
Yes
No
8. What is the best way for coaches to communicate with your child? (select all that apply)
Verbal instructions work well
Prefers visual instructions (demonstrations)
Comfortable with tactile instruction
Needs both verbal and visual instructions for better understanding
9. How does your child prefer to communicate? (select all that applies)
Natural Speech
Manual Sign
Gestures
No reliable method for communication
Augmentative Alternative Communication (AAC) If using AAC please specify (note if waterproof):
10. How does your child respond to transitions between activities? (select one)
Adapts easily
Needs warnings or visual schedules before transitions
Finds transitions difficult and benefits from structured routines
11. Does your child have any behaviors we should be aware of (e.g., elopement,emotional dysregulation, repetitive behaviors, stimulatory regulation)? Please note aggressive behaviors if any.
No significant behaviors
Requires a structured plan for specific behaviors (please describe and include triggers and helpful strategies):
11. Part 2 - Does your child have any behaviors we should be aware of (e.g., elopement,emotional dysregulation, repetitive behaviors, stimulatory regulation)? Please note aggressive behaviors if any.
No significant behaviors
Occasionally may need support (please describe triggers and helpful strategies):
12. If applicable, how many aggressive incidents do they have per week at school?
0
1
2
3
4
5
13. If applicable, how many incidents of emotional dysregulation does your child have at school?
0
1
2
3
4
5
14. Is your child prone to eloping?
Yes
No
15. What level of support do you feel would best suit your child at camp? (select one)
Tier 1 (Minimal Support): Can participate in regular activities with minor accommodations
Tier 2 (Moderate Support): Needs structured guidance, smaller groups, and extra transition time.
Tier 3 (High Support): Requires one-on-one support, highly structured activities, and individualized accommodations.
Submit
Should be Empty: