Supported Lesson Waiting List

Child's Name*

First NameLast Name

Date of Birth*

Date

Parent/Guardian's Name*

First NameLast Name

Relation to Child*

E.G Mother/Father

Email*

example@example.com

Phone Number*

Area CodePhone Number

Emergency Contact Name*

First NameLast Name

Emergency Phone Contact Number*

Area CodePhone Number

Please fill in the following with as much detail as possible so that we can understand the needs of your child. Once you near the top of the waiting list you will be contacted by email or phone to discuss the options available in more detail.

Things that make me anxious*

Things I like*

Things I dislike*

How best to support me*

Please tell us why supported lessons are important for your child*

Participant’s Needs

Please answer yes or no to the following questions about your child/young adult.

Are they comfortable in busy environments?*

YesNo

Are they comfortable in social situations?*

YesNo

Are they likely to behave unpredictably?*

YesNo

Are they likely to hurt themselves or others*

YesNo

Do they understand danger, and how to keep themselves safe?*

YesNo

Is your child comfortable with female and male instructors?*

YesNo

Does your child have support at school?*

YesNo

If in a Stockport school, please could you provide the school name*

Has your child got any swimming experience?*

YesNo

Please tell us about any reasonable adaptations we can make to ensure your child’s needs are met whilst swimming with us.*

Medical information

Please answer yes or no to the following medical questions about your child/young adult

Does your child have a disability or additional needs?*

YesNo

Does your child have a diagnosed learning disability?*

YesNo

Do they have epilepsy?*

YesNo

Do they have any other diagnosed medical condition e.g. Asthma, Heart Conditions?*

YesNo

Will access to medication or medical equipment be required during the session?*

YesNo

Can they communicate using spoken language?*

YesNo

Does your child have an EHC plan?*

YesNo

Please give brief description or any more information we need to be aware of*