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.

What our swimmers have to say:

"Thank you so much. As you said, we can't believe she is the same little girl who started in the pool with you. Thanks again." Mike, Marissa, & Keira
"Thank you for all your patience this summer with Jake. It's really paid off in his confidence in the pool and out! I admire you all for the ability to teach lifesaving skills in water to resistant and anxious children. WOW!!! That is so cool. You all are a neat group of people." Riki
I cannot thank you enough for all you have done for us this summer. Your patience and kindness has been so wonderful and has truly touched not only my daughter's heart, but mine as well. I am forever grateful for your generosity and love for my family!" love Amber

Read more testimonials.

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KAY'S ALL SWIM SCHOOL – since 1974 –

Register Now Online!

The BEST place to be is in a pool!

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 our swimmers have to say:

TOP 10 REASONS PARENTS GO TO KASS

Get Email Updates
Email

KAY'S ALL SWIM SCHOOL – since 1974 –

Register Now Online! The BEST place to be is in a pool!

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!

What our swimmers have to say:

TOP 10 REASONS PARENTS GO TO KASS

Get Email Updates

Register Now Online!

The BEST place to be is in a pool!