Aquatic Therapy and Disability-Specific Water Safety Program Enrolment Form
Parent/Carer's Details
Parent/Carer Full Name
*
First Name
Last Name
Relationship to the participant
E-mail
*
Confirmation Email
Mobile Number
*
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Which CrocStars Location would you like to book into?
Berkeley Vale
This is my preferred location
This is my second preferred location
I'm willing to consider this option if my preferred locations are not available
This location is definitely not an option for us
Woy Woy
This is my preferred location
This is my second preferred location
I'm willing to consider this option if my preferred locations are not available
This location is definitely not an option for us
Wyong
This is my preferred location
This is my second preferred location
I'm willing to consider this option if my preferred locations are not available
This location is definitely not an option for us
Lesson Details
Please record your 1st, 2nd and 3rd preference.
1st Preference
*
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred lesson time (you must give at least 2 options)
8.00am-9.00am
9.00am-10.00am
10.00am-11.00am
11.00am-12.00pm
12.00pm-1.00pm
2.30pm-3.30pm
3.30pm-4.30pm
4.30pm-5.30pm
5.30pm-6.30pm
6.30pm-7.30pm
Other
2nd Preference
*
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred lesson time (you must give at least 2 options)
*
8.00am-9.00am
9.00am-10.00am
10.00am-11.00am
11.00am-12.00pm
12.00pm-1.00pm
2.30pm-3.30pm
3.30pm-4.30pm
4.30pm-5.30pm
5.30pm-6.30pm
6.30pm-7.30pm
Other
3rd Preference
*
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred lesson time (you must give at least 2 options)
*
8.00am-9.00am
9.00am-10.00am
10.00am-11.00am
11.00am-12.00pm
12.00pm-1.00pm
2.30pm-3.30pm
3.30pm-4.30pm
4.30pm-5.30pm
5.30pm-6.30pm
6.30pm-7.30pm
Other
Preferred start date of lessons
Optional - Comments re: preferred days/times
Who will bringing your child to their lessons at CrocStars?
I (parent/carer who is filling out this form) will be bringing the participant every week
I (parent/carer who is filling out this form) will be bring my child most weeks, but sometimes it may be someone else
Relative or Friend
The participants support worker
Other
Full Name of this person
Relationship with child
Mobile Number
Participants Details
Participants Full Name
*
First Name
Last Name
Participants Full Name
*
First Name & Surname
D.O.B
*
/
Day
/
Month
Year
Date Picker Icon
Gender
*
Male
Female
Other
Is the participant part of the NDIS (National Disability Insurance Scheme) ?
*
NDIS (current participant)
The participant does not have an NDIS a current plan, but we are waiting for a plan meeting or for the plan to be processed
No
Other
How is the participants NDIS plan managed?
AGENCY (NDIA) managed
PLAN managed (by a Plan Management Provider)
SELF managed (you manage the plan and pay the bills directly)
Other
What type of lesson would you like to book your child into?
*
30 minute 1:1 Private Lesson
I would like to request a 45-60 minute private lesson
Medical Diagnosis (please select relevant boxes)
*
No known diagnosed conditions
Autism Spectrum Disorder (ASD)
Attention Deficit Hyperactivity Disorder (ADHD)
Sensory Processing Disorder (SPD)
Intellectual Disability (ID)
Global Developmental Delay (GDD)
Oppositional Defiant Disorder (ODD)
Pathological Demand Avoidance (PDA)
Obsessive Compulsive Disorder (OCD)
Dyspraxia
Down Syndrome
Genetic Disorder (please give more info below)
Person of Short Stature
Deaf
Hard of Hearing
Blind
Vision Impairment
Cerebral Palsy
Anxiety Disorder
Epilepsy
Other
Other Medical Conditions
*
NO other medical conditions
Allergies
Asthma
Diabetes Type 1
Diabetes Type 2
Heart Problems
Seizures (any kind)
Other
Diabetes Type 1 management plan
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Information about your child's other medical conditions (please give more details about these conditions if needed)
*
Seizure Management Plan (if needed)
Upload a File
Please attached your child's Seizure Management Plan
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DSM-5 severity levels for autism spectrum disorder (ASD)
Level 1 (“requiring support”)
Level 2 (“requiring substantial support”)
Level 3 (“requiring very substantial support”)
ADHD Information
Inattention
Hyperactivity
Impulsivity
Combined
Not sure
Medical Diagnosis (please record more information if needed)
Cerebral Palsy Information (please tick the relevant boxes.)
Quadriplegia
Hemiplegia
Diplegia
Spastic
Dyskinetic
Ataxic
Mixed Type (please describe below)
Gross Motor Function Classification System (GMFCS)
GMFCS Level 1
GMFCS Level 2
GMFCS Level 3
GMFCS Level 4
GMFCS Level 5
Not Sure
Communication Function Classification System (CFCS)
CFCS Level 1
CFCS Level 2
CFCS Level 3
CFCS Level 4
CFCS Level 5
Not Sure
Cerebral Palsy Information (please record more info if needed)
Communication (Expressive)
*
Verbal
Verbal (Limited)
Non Verbal
Other
Does your child use any of these communication methods or tools?
*
None
Key Word Sign
Auslan
PECS
Proloquo2Go
Visual Schedules at home and/or school
Other
Please tell us more about how your child's communication? For example - how long have they been using this method of communication for? which key word signs do they use?
Communication (Receptive)
*
Requires visuals for all information presented
Can follow a one-step instruction
Can follow multi-step instructions
Other
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We are legally required to undertake a risk assessment to ensure the safety and welfare of our students and staff. Please provide information that will assist us to have the appropriate controls in place.
Does your child have any of the following physical conditions that cause limited/restricted movement or that we need to be careful of in the water?
*
No known physical conditions
Scoliosis
Hip Dysplasia
Cerebral Palsy
Paraplegic
Quadriplegic
Feeding Tube
Diabetes Cannula
Other physical condition(s) that require specific care by our staff
Other
Please provide us some more information if needed
Attach information from specialist eg physio or paed which explains the above physical condition
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Is it common for your child to have any of the following behavioural challenges?
*
No known behaviours that could cause harm to themselves or others
Physical Aggression
Absconding
Biting
Hair Pulling
Hitting
Inappropriate/Offensive Language
Self Harm
Other
Behavioural Challenges (please provide us with more information about the issues above or any other known behavioural issues that we need to know about)
*
Behaviour Support Plan (if needed)
Upload a File
Please attached your child's Behaviour Support Plan
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Sensory Information
*
No known sensory issues
1. Body Awareness (Proprioceptive) - Sensory Seeking (hypo-sensitive)
1. Body Awareness (Proprioceptive) - Sensory Avoiding (hyper-sensitive)
2. Balance (Vestibular) - Sensory Seeking (hypo-sensitive)
2. Balance (Vestibular) - Sensory Avoiding (hyper-sensitive)
3. Touch (Tactile) - Sensory Seeking (hypo-sensitive)
3. Touch (Tactile) - Sensory Avoiding (hyper-sensitive / tactile defensive)
4. Noise (Auditory) - Sensory Seeking (hypo-sensitive)
4. Noise (Auditory) - Sensory Avoiding (hyper-sensitive)
5. Smell (Olfactory) - Sensory Seeking (hypo-sensitive)
5. Smell (Olfactory) - Sensory Avoiding (hyper-sensitive)
6. Taste (Gustatory) - Sensory Seeking (hypo-sensitive)
6. Taste (Gustatory) - Sensory Avoiding (hyper-sensitive)
7. Sight (Visual) - Sensory Seeking (hypo-sensitive)
7. Sight (Visual) - Sensory Avoiding (hyper-sensitive)
Please give us more information about your child's hypersensitivity or hyposensitivity issues.
Sensory Management Strategies
Upload a File
Please attached your child's Sensory Management Plan
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What are some of your child's interests?
*
What motivates your child?
*
What calms your child if he/she is upset?
*
What would your child do if they saw a body of water? Eg; jump in, be very cautious, would never go in without an adult
*
What would your child do if they fell into a body of water?
*
Information about the physical ability to enter the pool?
The participant can independently enter the pool by walking down the ramp access and holding onto the railing.
The participant will need assistance from the swim teacher to enter via the ramp access.
The participant will need to enter the pool via the hoist or chair lift .
Other
Is the participant toilet trained? (If no, they must wear suitable swim protection pants in the water. You will receive more information from CrocStars about this in your Welcome Pack)
*
Yes
No
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Please give information about the participants current experience with water? For example; bath time is an issue, has had a near drowning experience or maybe they love any water situation such as bath, beach and pools
*
Has the participant previously attended swimming lessons? If so, when, where, for how long and tell me briefly about the experience for you and your child?
*
Please rate your the participants swimming ability.
*
Nervous beginner
Beginner, but happy in the water
Can swim unaided with no stroke
Beginning to learn basic stroke
Needs stroke development
Other
What are your goals for the participants sessions with CrocStars?
*
Other information that may help in teaching your child
*
Education, Activities and Therapies
This information gives us a better understanding of the level of supports needed.
Current Education or Supports during the week
Mainstream School
Support Class within Mainstream School
Multi-Categorical Support Unit
Specialised School for children with a disability
Home Schooling
TAFE
University
Day programs for adults with disabilities
No longer attending school or any other tertiary education
What other activities or sports does the participant attend?
*
Other Information
Where did you hear about us?
*
Google Search
Therapist
Recommendation on Social Media
Friend
Facebook
Autism Swim
Swim Australia
Other
Please verify that you are human
*
By completing this enrolment form, I understand my email address will be added to the contact list. You will receive emails to notify you about available lesson times and upcoming news. You will not receive junk emails.
*
Yes
Do you consent to photographs of your child being taken for CrocStars and Autism Swim social media/website/internet content?
*
Yes
No
Do you consent to your child's swimming data being used as part of a research study?
*
Yes
No
Signature
Thank you for completing our online enrolment form. Please click onto the submit button to send to our head office for review.
Submit
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Office Use Only
To be completed by CrocStars Management
Record participants goals and identify the risks and controls for the activities.
Risk Priority
1.
2.
3.
Submit
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