Runway Student Information

Class Time*

1:30 pm

Participant's Name*

First NameLast Name

Age*

Parent's Name*

First NameLast Name

Parent's Phone Number*

Area CodePhone Number

Parent's E-mail Address*

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

In order for us to get to know your child, please answer the following questions:

Does your child have previous runway experience?

Does your child exhibit sensitivity to touch?*

YesNo

Please explain.

Does your child exhibit sensitivity to sounds?*

YesNo

Please explain.

Does your child exhibit non-compliant behaviors requiring more assistance other than redirection?*

YesNo

Please explain.

Are there any medical issues we need to be aware of? *

Please check all that apply

Eye Contact *

Maintains eye contactOccasionally makes eye contact with the other personGlances in the direction of the other person but does not make direct eye contactAvoids eye contactStares at the floor

Communication*

Communicates using complete sentencesCommunicates using single wordsCommunicates using signs and gesturesDoes not communicate verbally or with signs and gestures

Willingness to participate during structured activities*

Responds to adult instructionParticipates with minimal prompting or redirectionWarms up to new activitiesVery often refuses to participate in structured activities

Is there anything else you would like us to know about your child?

Please attach a picture of the participant*

Upload a File

*Please note, this runway class is not suited for children with high behavioral support needs (one on one). DSALA wishes to provide a pleasant experience for all participants. Therefore, a parent or guardian must be present for the duration of each class to ensure that each participant is following class rules.

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