Autism Society of Greater Akron

PARENT / GUARDIAN INFORMATION

IMPORTANT NOTE:
Please ADD info@autismakron.org to your email contact address book to ensure emails do not go to your junk folder. If you do not see an email after registering, please check your junk folder.

Guardian First Name(*)

Invalid Input

Guardian Last Name(*)

Invalid Input

Guardian Race (For Grant Purposes Only)(*)

Invalid Input

Street Address(*)

Invalid Input

City(*)

Invalid Input

State(*)

Invalid Input

Zip(*)

Invalid Input

Phone(*)

Invalid Input

Phone Above Is(*)

Cell PhoneHome Phone

Invalid Input

Email(*)

Invalid Input

Confirm Email(*)

Invalid Input

SWIMMER - GENERAL INFORMATION

First Name(*)

Invalid Input

Last Name(*)

Invalid Input

Gender(*)

MaleFemale

Invalid Input

Date of Birth(*)

Invalid Input

Swimmer Race (For Grant Purposes Only)(*)

Invalid Input

SWIMMER - MEDICAL INFORMATION

Primary Diagnosis(*)

Invalid Input

Second Diagnosis (if any)

Invalid Input

Food Allergies (if any)

Invalid Input

In the box below, please provide any detailed information regarding the above diagnosis that will help us work with your swimmer safely and effectively. Explain any health/medical conditions or concerns and any related special instructions.

Invalid Input

CHOOSE LESSON TIME

This program involves 9 weeks of individual lessons lasting 30 minutes and scheduled on Tuesday and Thursday each week at the YMCA located at 477 E Market Street, Akron OH 44304. MAKE UP LESSONS: This program has set dates and times for execution with make up lessons only scheduled should the YMCA have to cancel a lesson due to pool shut down or inclement weather. If a swimmer is not able to attend a lesson due to illness, instructors will adjust instruction accordingly to keep swimmers on task.

Please make a first and second choice. We will do our best to honor your first choice, but this might not always be possible due to availability. Swimmer will attend lessons at these days and times each week.

Preferred Time(*)

6:00 pm (FULL)

6:30 pm (FULL)

7:00 pm (FULL)

7:30 pm (1 spot left)

Invalid Input

2nd Choice(*)

SWIMMER - WATER EXPERIENCE

Explain your swimmer's capabilities in the areas that follow so we can begin to get to know them.

My swimmer can ....

COST(*)

Pay Registration Fee - 400.00 USD

Use County Board of DD Funds

Invalid Input

JA Beranis

Swimming With Autism - Registration Form - Spring 2023