Special Abilities Intake Form SFAA UPDATED Nov. 11th

Special Abilities Intake Form

Thank you for choosing Roots Swim School to help your swimmer learn and grow! Please fill out the information below to assist us in best placing your child in the correct lessons. Our Aquatics Director will be in touch to schedule an evaluation.
Please select the type of lessons you are interested in below
Parent or Guardian: Primary Contact:
Relationship:

Other
Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Name of Child
DOB

MonthDayYear
Date of Birth
Age
Previous Swimming Experience:
Does your child have swimming experience?
Have they taken swim lessons or do they swim at home?
Medical Information:
Diagnosis
Allergies
Other medical concerns
Does your child have seizures?
If yes please explain
Goals for Swim Lessons
Goal 1 for lessons
Goal 2 for lessons
Goal 3 for lessons
Developmental/Cognitive Level:
In order to meet your child's needs please check off all that may apply.
Communication Style:
Please select how your child communicates best:

Other
Learning Style:
Please select the learning styles that helps your child learn best:

Other
Things your child likes to help motivate them (games, toys, shows):
Things your child dislikes (any triggers):
Calming Strategies used at home:
Does your student require assistance with any of the following? Check all that apply.
Is your Child potty trained?
Swim Lessons Preferences:
Before engaging in an activity:

Other
During Activity:

Other
Please select all that apply for the following sections in order to help gather additional information to meet you child's needs:

Sensory Preferences
Touch
Sight
Noise
Oral
Crowds
Smell
General
Any other additional information that you'd like to share to help US meet your child's needs
Thank you for completing our Special Abilities Intake Form!

We truly appreciate you taking the time to share more about your child. The information you’ve provided helps our team better understand your swimmer’s unique needs, strengths, and goals — allowing us to create the most positive and supportive experience possible. Our staff will be reaching out soon with the next steps in your swimmer’s journey with us. Whether your child is joining group classes, private lessons, or one of our monthly specialty events, we’re so excited to connect and get started! Please direct all questions to Jenn Butler- Burns our Aquatics Director at jennb@rootsaquatics.com
Date

MonthDayYear
Date
Parent/ Guardian Signature

First NameLast Name
Should be Empty:

Goals for Swim Lessons

Swim Lessons Preferences:

Please select all that apply for the following sections in order to help gather additional information to meet you child's needs:

Thank you for completing our Special Abilities Intake Form!