Swimming With Autism - Registration Form - Spring 2019


PARENT / GUARDIAN INFORMATION
Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input


SWIMMER - GENERAL INFORMATION
Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input


SWIMMER - MEDICAL INFORMATION
Invalid Input

Invalid Input

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 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.

Invalid Input

Invalid Input

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
Invalid Input

Put their face in the water
Invalid Input

Submerge their head under water
Invalid Input

Float on their stomach
Invalid Input

Float on their back
Invalid Input

Push off the wall
Invalid Input

Move their arms in the water
Invalid Input

Kick their legs
Invalid Input

Move their arms and legs together in the water
Invalid Input

Blow bubbles in the water
Invalid Input

Hold breath under water
Invalid Input

Swim more than 15 feet in the pool
Invalid Input

Additional information you would like us to know about your swimmer when considering them for this program.
Invalid Input


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!