Special Needs Intake Form
Welcome! Our mission is to allow children 3-11 years old with special needs to have fun while acquiring water safety and basic swimming skills. The following questions will help us lead your child to swimming success! See additional information about pricing and guidelines on our website https://www.hubbardswim.com/privatelessons
All Special Needs classes are currently on a waitlist.
Submitted forms will be contacted once we have a class available.
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SWIMMER'S BASIC INFO
Swimmer's Name
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First Name
Last Name
Gender
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Please Select
Female
Male
Current Age
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Available for children 3 through 11 years old
Social / Developmental Age
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Primary Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
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ENROLLMENT REQUEST
Please select your preferred location and all the times your swimmer can consistently attend year-round. Since our waitlist can take several months, please base your availability on your typical schedule over the next 12 months, not just the next few weeks.
Swim Location
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Please Select
Phoenix (32nd St & Thunderbird)
Peoria (84th Ave & Thunderbird)
Riverview (202 & Dobson Rd)
Goodyear (Pebble Creek Pkwy & McDowell)
Offered Friday afternoons from 3:00 - 6:00p. Please select times you are available.
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3:00
3:30
4:00
4:30
5:00
5:30
6:00
Offered Friday afternoons from 3:30 - 6:30p. Please select times you are available.
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3:30
4:00
4:30
5:00
5:30
6:00
6:30
I currently have an account with my student listed at the location I listed above to process my request and allow future communication by email.
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YES!
No, but I will within 1 hour of submitting this request. I understand my enrollment request will become inactive if I do not have an account created with my student listed. https://www.hubbardswim.com/register
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On rare occasions, weekday Special Needs classes before 2:00 pm become available at our Phoenix location. Please select the days that would typically work for your family throughout the year, as openings may occur several months from now.
Monday 9:00am-1:00pm
Tuesday 9:00am-1:30pm
Wednesday 9:00am-1:00pm
Thursday 9:00am-1:30pm
Friday 9:00am-11:30am
On rare occasions, weekday Special Needs classes before 2:00 pm become available at our Peoria location. Please select the days that would typically work for your family throughout the year, as openings may occur several months from now.
Tuesday 9:00am-1:30pm
Wednesday 9:00am-1:30pm
Thursday 9:00am-12:00pm
On rare occasions, weekday Special Needs classes before 2:00 pm become available at our Riverview location. Please select the days that would typically work for your family throughout the year, as openings may occur several months from now.
Wednesday 9:00am-12:00pm
Thursday 9:00am-12:00pm
On rare occasions, weekday Special Needs classes before 2:00 pm become available at our Goodyear location. Please select the days that would typically work for your family throughout the year, as openings may occur several months from now.
Monday 9:00am-1:30pm
Tuesday 9:00am-1:30pm
Wednesday 9:00am-11:30am
Thursday 9:00am-11:30am
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MEDICAL INFORMATION
Is your child toilet trained?
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Yes
No - we require a reusable Happy Nappy cloth swim diaper (up to 4T available on location)
5T and up can be purchased at www.theraquatics.com
Does your child aspirate
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Yes
No
Is your child on thickened liquids?
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Yes
No
Diagnosis Information
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Are there any physical limitations we should be aware of? Ex: Difficulty with balance, coordination, muscle weakness.
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Optional: Is your child currently participating in any therapy sessions (OT, PT, ABA, Speech, etc)? If so, please let us know anything that might be helpful. This helps us better support your child's experience in lessons.
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COMMUNICATION INFORMATION
Expressive Language: Please describe how your child communicates best with others.
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Full Sentences
1-2 words
Gestures
AAC Device (Augmentative and Alternative Communication)
PECS (Picture Exchange Communication System)
ASL (American Sign Language)
Eye Gaze Device
Other
Receptive Communication: Please select the option that best describes your child's receptive language and ability to understand/perform 1-2 step directions.
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My child can understand and complete 1 step directions most of the time
My child can understand and complete 2-3 step directions most of the time
My child needs some assistance with 1 step directions
Is your child familiar with token boards, visual schedules or first/then language?
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Please provide any additional information that may help an instructor regarding communication.
*
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BEHAVIORAL INFORMATION
Please provide any behavioral or adaptive strategies that you would like to share.
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Does your child have aggressive behavior? Ex: Biting, pinching, hitting, etc.
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Yes
No
Please provide details, possible triggers and strategies for handling in a class and aquatic environment.
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CHILD INFORMATION
Special interests or favorite things? Please also include positive reinforcers and any fears or dislikes.
*
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SWIM EXPERIENCE
Please describe your child's history with water/swimming. Ex: Have they gone under the water before? Have they had lessons? Have they worn a flotation device? Please provide as much detail as possible on swim skills and safety cognizance.
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Is your child...
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Over confident
Anxious/nervous
Willingly putting their face in the water
Water Safety Awareness: Does your child have regard for basic safety rules around the pool? Ex: walk don't run, wait for an adult before entering the pool.
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Yes
No
Would your child be safe in a group class with four (4) students? Ex: Waiting their turn, following directions.
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Yes
No
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Goals
What goals do you have for your child in this program?
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PLEASE NOTE
HFSS currently has a waitlist for all Special Needs classes. We will contact you by text and email as soon as an opening becomes available.
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Yes. I am interested in being contacted when a class is available based on my availability summited.
If I am no longer interested in the waitlist or my availability changes I will contact SpecialNeeds@hubbardswim.com with this information.
Due to scheduling constraints, we are unable to offer makeup lessons for swimmers with special accommodations. Our locations do not have teachers available outside of scheduled classes, which prevents us from fitting in one-on-one makeup sessions.
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Yes. I understand my swimmer will not be eligible for makeup lessons or financial credit if I am unable to attend my lesson. Ex: Vacations, illness, scheduling conflict, etc.
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