Special Needs Questionnaire

Child's Name*

Approximate Height*

Chronological Age*

Weight*

Developmental Age*

Gender*

•    Male
•    Female

Adult's First Name*

Adult's Last Name*

Email*

Best Contact Number*

How did you hear about Kay's All Swim School?*

Our mission with special needs students is to allow them to have fun while exploring the water. The following questions will help us lead your child to a positive swimming experience!

What is the child’s diagnosed special need?*

What is your child’s experience in the water?*

Does your child communicate verbally? What is the best communication method?*

Is your child on a behavior plan that we could support (cue words, hand signals, picture schedule, etc)?*

Are there any physical limitations the instructor should be aware of?*

Are there any body movements we should encourage or discourage?*

Has your child used ‘floaties’ or a floating device before?*

Are there any specific reinforcements that help your child succeed at home or school?*

What goals do you have for your child in this program?*

Other important information we should know about? (i.e. fears, negative experiences, potty trained?, what makes your child happy, etc)?*

Does your child have defiant behaviors? Does your child have physical or verbal aggression? (If yes, please explain)*

 

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