Old Pueblo Gymnastics - Adaptive Gymnastics Interest Form

Adaptive Gymnastics Interest Form
Parents - please provide the following information. This information will assist our occupational therapists in determining an appropriate placement for your child. We will be contacting you soon to advise you of the next steps!
Parent Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Student Name*

First NameLast Name
Gender*

MaleFemale
Child's Date of Birth*

MonthDayYear
Date
Special Needs Focus (i.e. autism, cerebral palsy, down’s syndrome, etc.)*
Level of Severity (mild to severe)*
Any special considerations?
I am interested in:

I am interested in classes during the school daysI am interested in classes after schoolI am interested in private lessons during the school dayI am interested in private lessons after school
Does your child have difficulty with loud noises and/or crowded places?*

YesNo
If so, please explain.
Does your child avoid being touched or have aversions to being touched by others?*

YesNo
If so, please explain.
Does your child get frustrated easily?*

YesNo
If so, please explain.
Does your child have difficulty with running away or leaving a group during structured tasks?*

YesNo
If so, please explain.
Does your child have any mobility limitations?*

YesNo
If so, please explain.
How does your child do with following directions? (i.e. one step versus multiple steps)
How does your child get along with other children?
Does your child have difficulty with coordination and learning new skills?*

YesNo
If so, please explain.
Does your child seek out intense movements (i.e. crashing, jumping, running) or seem to be in constant motion?*

YesNo
If so, please explain.
Does your child avoid or hesitate doing certain types of movement (i.e. going up stairs, sliding, swinging, etc.)?*

YesNo
If so, please explain.
Does your child have any previous gymnastics experience?
Child's Availability for Classes or Private Lessons (please check any your child is available for):

Monday afternoons (3-6)Tuesday mornings (9-12)Tuesday afternoons (3-6)Wednesday afternoons (3-6)Thursday afternoons (3-6)Friday mornings (9-12)Friday afternoons (3-6)Saturday afternoons (12-3)Sunday mornings (9-12)
Should be Empty: