Swimming With Autism - Registration Form - Spring 2018


PARENT / GUARDIAN INFORMATION
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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Phone Above Is(*)
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Email(*)
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Relationship to Swimmer(*)
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SWIMMER - GENERAL INFORMATION
First Name(*)
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Last Name(*)
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Gender(*)
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Date of Birth(*)
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Swimmers Age(*)
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SWIMMER - MEDICAL INFORMATION
Primary Diagnosis(*)
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Second Diagnosis (if any)
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Food Allergies (if any)
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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.
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CHOOSE SESSION TIME
This program involves 10 weeks of individual lessons lasting 30 minutes and scheduled on Monday and Thursday at the YMCA located at 477 E Market Street, Akron OH 44304.

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. Participant will attend lessons at this time on both Monday and Thursday each week of the program.
Preferred Time(*)

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SWIMMER - WATER EXPERIENCE
Explain your swimmer's capabilities in the areas that follow so we can ensure this program is a good fit for them.

My swimmer can ....
Climb in and out of the pool
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Put their face in the water
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Submerge their head under water
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Float on their stomach
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Float on their back
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Push off the wall
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Move their arms in the water
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Kick their legs
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Move their arms and legs together in the water
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Blow bubbles in the water
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Hold breath under water
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Swim more than 15 feet in the pool
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Additional information you would like us to know about your swimmer when considering them for this program.
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PROGRAM REMINDER
Please note that completing this participant registration form does not confirm or guarantee acceptance of the participant in the Swimming with Autism program. The form will be reviewed and you will be contacted via email within 3 business days as to the status. Session times are granted on a first-come first-serve basis. Thank you for your interest in this program!