Autism Society of Greater Akron

REQUEST TO BE ADDED TO WATER SAFETY WAITING LIST

First Name(*)

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Last Name(*)

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Street Address(*)

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City(*)

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State(*)

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Zip(*)

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Phone(*)

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Email(*)

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Confirm Email(*)

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Swimmer Name(*)

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Birthdate of Swimmer(*)

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Age of Swimmer(*)

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Swimmer Diagnosis(*)

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Is swimmer served by a County Board of DD?(*)

Yes

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What type of funding does swimmer receive from County Board?

Family Engagement Funds (FEP)

Waiver

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