Parent/ Guardian Information *

First Name

Last Name

Phone

(###)

###

####

Child's Name ( First and Last) *

First Name

Last Name

Child's Specific Diagnosis *

Autism

ADD/ADHD

Sensory Processing

Speech Delay

Developmental Disability

Learning Disability

Is your child a client of Valley Mountain Regional Center? *

Yes

No

Is your child toliet trained?

Yes

No

Does your child have a history of seizures? *

Yes

No

If your child comfortable in the water? *

Yes

No

Please share how your child prefers to communicate. *

verbal

signs

gestures

PECS

What goals do you have for your child regarding swim skills & water safety?

To become comfortable in water

Enter and exit water independently

Float on back

Perform basic arm and leg movements

Tread water

Develop comfort and familiarity with water

Improve basic water safety skills (e.g., floating, treading water)

Learn basic swimming strokes (e.g., front crawl, backstroke)

Swim with floatation device