Sonoran Dolphins Welcome Form

1. Swimer's Name
2. Age
3. DOB

Contact Name/Email/Ph:

MEDICAL INFORMATION:

1. Diagnoses
2. Allergies

Do any of the following apply to the swimmer?

• 1. Seizures
  YesNo
  if yes, how frequently?
  
  Date of last seizure
  

2. Aggressive Behavior
YesNo

if yes, how frequently?

If yes, please explain.

COMMUNICATION INFORMATION:

• Expressive:
  • Verbal
  • Verbal(limited)
  • Non-Verbal
• Sign:
  • Language(talking)
  • PECS
• Augmentative Device:
  • Verbal
  • Written
  • Gestural
• Other:
  • Written
  • Picture
  • Object
• Perceptive:
  • Yes
  • No
• Uses Visual Schedule:
  • Yes
  • No