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?

• • Seizures
• (if yes, how frequently?
• Date of last seizure)
• • Aggressive Behavior
• If yes, please explain.
• • Incontinence
• If yes, please explain.
• • Ostomies/GI Tubes
• If yes, please explain.
• • Cardiac Conditions
• If yes, please explain.
• • OTHERS?
• 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