COVID-19 Daily Health Screening Form
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Home
Programs
Gymnastics
Aquatics
Sports & Athletics
Fitness & Training
Physical Therapy
Day Camps
Browse by Participant
Youth Programs
Adult & Teen Programs
Special Abilities
Parties & Events
Kids Parties
Parents Night Out
Special Abilities PNO
Turf Rental
About Us
Our Facility
Pricing Info
FAQs
Contact Us
Class Portal Login
Special Abilities Intake Form
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Name of Child
*
First
Last
Child's Age
Child's Date of Birth
MM
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DD
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YYYY
2021
2020
2019
2018
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2016
2015
2014
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1931
1930
1929
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1927
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1925
1924
1923
1922
1921
1920
Parent/Guardian Name
*
First
Last
Email
*
Phone
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Best time to contact you:
Morning
Afternoon (before 5pm)
Evening (after 5pm)
Best time to schedule child's evaluation:
Morning
Afternoon (before 5pm)
Evening (after 5pm)
How did you hear about our program?
What is your child's specific diagnosis?
Does your child have IEP?
Yes
No
What is child's functional level?
High Functioning
Moderate
Low Functioning
Does your child need assistance with any of the following?
Walking
Remaining with a group
Grasping/manipulating objects
Toileting
Listening/following directions
Other
How does your child communicate?
Verbal
Non-verbal
If your child is non-verbal, what form of communication is used?
Describe any special medical needs or allergies that we should know about.
*
Are there any special accommodations necessary for physical disabilities?
Has your child participated in any other recreational activities?
Yes
No
If yes, please list activities:
What are your goals for your child in our program?
How would you describe your child’s personality?
Is there anything else that you would like to share about your child?
Submit
