SEALS Team Swim Lesson Registration

MM slash DD slash YYYY

General Information

Applicant's Name
MM slash DD slash YYYY
Primary Contact Parent/Guardian Name
Additional Contact Parent/Guardian Name
Primary Guardian Address
Preferred Times
Preferred Day
Is this the applicant’s first experience in a pool?
Is the applicant comfortable putting their face in the water?
Is the applicant afraid/fearful of the water?
Can the applicant swim any distance unassisted?
Has the applicant had any swim lessons?

Medical Information

What is the applicant’s diagnosis? Please check all applicable boxes.
Please note the program is grant funded and is being offered to special needs individuals who are not capable of being integrated into an able-bodied program.
The applicant:
Does the applicant have any other medical concerns?