Registration Name * First Last Child(rens) Name(s) * Phone * Email * Date * Requested Time Morning Afternoon Late Afternoon Requested Day Mon Tues Wed Thur Fri Sat (San Diego) Sun Medical Information Medical Diagnosis * How did you hear about Special Fishies? (if referred please list name) * Does your child/children have any allergies? * Does your child/children have other medical concerns? * Does your child/children exhibit aggressive behavior? If yes, explain. * Communication Expressive Language * Uses visual schedule Social interests and other Please list any other Interests. Please list some things that work to positively reinforce behaviors. * Please list some things that might present as fears/dislikes. * Do you have any behavioral strategies that you would like to share? Would you like any specific speech or communication worked on during swim lessons? If so, what specifically? Water and movement is proven to be beneficial to promoting speech! Any other areas to work on during swim lessons? Aquatic Strengthening, Aquatic Freedom, PT Goals, OT Goals, Socialization, Coordination, Conditioning, etc. Liability Release / Waiver Please read the Liability Release/Waiver Please select at least one checkbox.Please check the box * I agree to the conditions in the Liability Release/Waiver Submit Please be sure to also submit our Policy & Procedure Agreement. Policy & Procedure
