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Adaptive Aquatics & Sensory Swim
"If they can't learn the way we teach, we teach the way they learn." -Dr O Ivar Lavaas
12
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1
Parent Name
*
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First Name
Last Name
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2
Email
*
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example@example.com
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3
Phone Number
*
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Please enter a valid phone number.
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4
Child Name
*
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First Name
Last Name
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5
Child's Birthdate
*
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-
Date
Year
Month
Day
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6
Diagnosis
*
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please describe the child's diagnosis and specific needs
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7
Communication
*
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how does your child communicate best (please explain both receptive and expressive)
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8
Swim History
*
This field is required.
has never been in the water
loves the water but is unsafe
fearful/hesitant around water
swims with floatation device
swims with head above water
other
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9
Behaviors
*
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please explain any known triggers and the child's reaction to triggers
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10
Goals
*
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select all that apply
water safety
comfort in water
independence in water
endurance
strength
motor skill development
basic swim skills
other
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11
What type of lessons are you interested in?
*
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Please Select
SKILL DEVELOPMENT - weekly classes, private one-on-one with the instructor, recurring monthly payment
5-DAY KICKSTART - five consecutive days, private one-on-one with the instructor, one-time payment
SENSORY SWIM - weekly classes, interactive class with a parent in the water, recurring monthly payment
Please Select
Please Select
SKILL DEVELOPMENT - weekly classes, private one-on-one with the instructor, recurring monthly payment
5-DAY KICKSTART - five consecutive days, private one-on-one with the instructor, one-time payment
SENSORY SWIM - weekly classes, interactive class with a parent in the water, recurring monthly payment
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12
Additional Information
*
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please explain any additional information that may be beneficial
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