Adaptive Aquatics& Sensory Swim Survey

1
Parent Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Child Name* This field is required.
First Name
Last Name
5
Child's Birthdate* This field is required.
Date
Year
Month
Day
6
Diagnosis* This field is required.please describe the child's diagnosis and specific needs
7
Communication* This field is required.how does your child communicate best (please explain both receptive and expressive)
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
9
Behaviors* This field is required.please explain any known triggers and the child's reaction to triggers
10
Goals* This field is required.select all that apply
water safety
comfort in water
independence in water
endurance
strength
motor skill development
basic swim skills
other
11
What type of lessons are you interested in?* This field is required.
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
12
Additional Information* This field is required.please explain any additional information that may be beneficial
Huge
Large
Normal
Small
Ok
Ok
13
We have partnered with Swim Angelfish in order to elevate our skills to teach swimmers with ADHD, Autism, Down Syndrome or any type of emotional, physical or sensory challenge. This innovative program unlocks time-tested methods to teaching swimmers who need a different approach.

Swim Angelfish provides FREE resources for families, as well. Click the link below to find out more:

https://swimangelfish.com/water-safety-for-all-abilities/

Swim Dynamic is not affiliated with Swim Angelfish, LLC, nor endorsed by Swim Angelfish, LLC or any of its affiliates or members.
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