Year-Round Swim Lessons at Swim With Gills - Expert Swimming Instruction for All Ages

Class Details

This information will be used for the sole purpose of Swim With Gills helping to meet your child's needs. If we don't know, we can't accomodate! No child belongs in a teaching 'box'!

office@swimwithgills.com

Does the participant have any medical condition of which the instructor should be aware? For example, diabetes or suffers from seizures, allergies.

Yes

If yes, please explain:

What accommodations, if any, does the individual need in order to participate in swim lessons?

What type of reinforcement and/or rewards work best to keep the participant motivated and focused (stickers, candy, worksheets)?

*For Participants with Disabilities or Other Health Conditions please fill out our additional Questionnaire.

*Additional Questionnaire for Participants with Disabilities or Other Health Conditions

This information is to be used for the sole purpose of the Swim With Gills, LLC to meet the needs of the participant in swim lessons.

Does the participant have any disability or other health condition that we should be aware of (such as a seizure disorder or allergies)? If seizures are a part of the health condition, please complete the "For Participants with a Seizure Disorder" section of this form. Please include silent seizures.

What accommodations, if any, does the individual need in order to participate in swim lessons?

What, if any, are the participant's fine motor skills/limitations (such as grasping or manipulating objects)?

What, if any, are the participant's gross motor skills/limitations (such as walking, throwing or jumping)?

How does the participant communicate?

Verbally

Non-verbally

Sign Language

Communication Board

If the participant has difficulty communicating, what is the degree of difficulty?

Is the participant usually able to listen to and follow directions appropriately?

Does the participant exhibit any behaviors that might interfere with programming (non-compliance, hitting self or others or tantrums)?

Is the participant currently on a behavior management program? If yes, please describe:

Receiving Treatment? Yes or No, Type of Disorder:

What is the likelihood and frequency of seizures during program hours?

Describe a typical seizure pattern including typical length of seizure:

I, the undersigned, as the parent or legal guardian of the child listed on this application in consideration of the request and permission of my son / daughter to participate in Swim With Gills, LLC programs.

Adaptive Aquatic Request Form

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