Settings

Swimming Signup and Forms

Swimming Signup and Forms


Please click on the liability waiver and sign it. Then fill out the form below and submit your signed liability waiver by uploading it at the bottom of the form.

Swim Questionaire

General Information

Does the child have a fear of water?

Parent / Guardian Information 1

Does this parent / guardian reside with the participant at the address above?

Parent / Guardian Information 2

Does this parent / guardian reside with the participant at the address above?

Emergency Contacts

Diet and Activity

Diet Restrictions?
Activity Restrictions?

Allergies

Medications

Health History

Every been hospitalized?
Every had surgery?
Have recurring / chronic illness?
Had a recent infectious disease?
Had a recent injury?
Had asthma/wheezing/shortness of breath?
Passed out/chest pain during exercise?
Had seizures?
Had feinting or dizziness?
Had headaches?
Problems with diarrhea/constipation?
A history of bedwetting?
Problems with falling asleep/sleepwalking?
Wear glasses, contacts, or protective eyewear?
Ever had back/joint problems?
Have any skin problems?
Have diabetes?
Had “mono” in the past 12 months?
Traveled outside the country in the past 9 months?
If female have problems with periods/menstruation?

Mental, Emotional, and Social Health

Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)?
Ever been treated for emotional or behavioral difficulties or an eating disorder?
During the past 12 months seen a professional to address mental/emotional health concerns?
Had a significant life event that continues to affect the participant’s life (abuse, death of a loved one, divorce, adoption, foster care, new sibling, survived a disaster)?

Insurance

Is the participant covered by family medical/hospital insurance?

Primary Care Provider

Dentist

Orthodontist

Maximum upload size: 2.1MB
Categories
Join Our Facebook Community

Contact Us Today For Class Information

Contact Us Today For Class Information