Special Needs Questionnaire

							
																			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)*						

You will know this form has been successfully submitted
 
when you see the Thank You page.

You must submit a Registration Form along with the Special Needs questionnaire.

What our swimmers have to say:

"My child accomplished more in 1 session at Kay's than a year at another program!"
"About 20 years ago you taught my two boys to swim. Well, I have a new little one. He's 3 years old now. I've been taking him to lessons elsewhere and I'm having the same problem I had with the older boys that ultimately led me to you those many years ago. The water is too cold and my son can't focus when he's freezing! I look forward to getting back to you and your warm water!" Thank you, Denise
"I would never consider going anywhere else because you look at the whole child." Kiley

Read more testimonials.

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KAY'S ALL SWIM SCHOOL – since 1974 –

REGISTER ONLINE NOW!

Join us for 50+ years of Excellent Swim Instruction.

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!

You must submit a Registration Form along with the Special Needs questionnaire.

What our swimmers have to say:

TOP 10 REASONS PARENTS GO TO KASS

Get Email Updates
Email

KAY'S ALL SWIM SCHOOL – since 1974 –

REGISTER ONLINE NOW! Join us for 50+ years of Excellent Swim Instruction.

Special Needs Questionnaire

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!

You must submit a Registration Form along with the Special Needs questionnaire.

What our swimmers have to say:

TOP 10 REASONS PARENTS GO TO KASS

Get Email Updates

REGISTER ONLINE NOW!

Join us for 50+ years of Excellent Swim Instruction.