Autism Swim- Parent Intake form
Swimming lessons
Parents full name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Childs full name
First Name
Last Name
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Has your child participated in lessons before?
Please Select
yes
no
How does your child feel about the water?
Please Select
loves it
hates it
very nervous
mixed
Can your child put their face under water comfortably?
yes
no
Can they blow bubbles in the water?
yes
no
learning
Can they kick with a board?
yes
no
learning
Can they tread water?
yes
no
learning
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Does your child understand pool rules and follow instructions around water?
yes
no
Can your child safely enter and exit the pool (ladder, edge, steps)?
yes
no
Does your child know how to safely roll onto their back for a rest?
yes
no
Has your child practiced survival skills (floating, calling for help, basic rescue techniques)?
yes
no
Can they float (front / back)
with assistance
with no assistance
with aids
they don't like it
Can they use basic arm movements (dog paddle, freestyle, backstroke, etc.)?
dog paddle
freestyle
all of the above
None
backstroke
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Can they swim short distances without support (please estimate how far, if so)?
What are your main goals for your child (e.g. water confidence, stroke development, survival skills)?
Are there any fears, challenges, or behaviours we should be aware of?
Does your child have any medical, sensory, or physical needs we should consider during lessons?
What helps your child stay calm and engaged if they feel overwhelmed?
Submit
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