Special Needs Profile Form

Safety Before Skill

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Special Needs Swimmer Profile
Profile was designed by Dennis Developmental Center

* Indicates required field

Swimmer's Name *

First

Last

Parent or Guardian Name *

First

Last

Age *

Email *

Phone Number *

Diagnosis *

Communication Information

#1 What is your swimmer's expressive communication level? *

Verbal Limited Verbal Skills Non-Verbal Sign Language Pictures or PECS to Communicate Augmentative Device

#2. What is your swimmer's receptive communication level? *

Follows complex directions verbally Follows simple directions verbally Follows written/picture directions Follows gestures and imitation

#3. How do you best communicate directions to your swimmer, and how do they respond to you? *

Social Information

#4. How much does your swimmer interact with other children? With other adults? *

#5. Does your child understand and join in to pretend play? Back and forth reciprocal play? *

Yes NO

#6. What is the best way to approach your swimmer to get them comfortable with new people? *

Fears & Sensory Issues

#7. Are there sensory issues that are particularly difficult for your swimmer? (i.e. smells like chlorine; echo in the pool area; loud sounds, water touching them etc.) *

#8. Does your swimmer have any fears? (Please list) How do they usually respond? *

#9. What are the typical causes of any emotional melt-downs for your swimmer? *

#10. What are the best ways you have found to handle these? *

Adaptability

#11. How does your swimmer respond to changes in routine? *

#12. Does your swimmer display any motor mannerisms? If so, what are they trying to tell us? (excited, upset, etc.) *

Motivation & Best Qualities

#13. What do you use to help motivate and reward your swimmer? *

#14. What do you think will help us make swimming lessons fun and a good learning experience for your swimmer? *

#15. What are your swimmer's great qualities? *

#16. Would you like any specific skills emphasized while we work with your swimmer? If so, please be as specific as possible. (i.e. working on using full sentences; working on asking for more; large motor or small motor skills) *

Thank you for taking the first step to water safety for your swimmer.
We can't wait to see you at the pool!

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classes

Private Lessons
Parent & Me
Club Swim
Adult Aquatic Class
A La Carte Lessons

special Programs

Home Lessons
Aquatic Fitness & Training
Special Needs Program
Lifeguard Service
Book An Exchange

Locations

West Little Rock
Conway
Coaches Corner
HOME

Client Services:
(501) 940-1287

Rainout Line:
(501) 486-0041

Home
"TRY IT" FOR FREE
LESSONS
Locations
Lap & Family Swim For Fitness
LIFEGUARD/CPR SERVICES
Babysitting Certification
PRESCRIPTION PROGRAM
- Water Babies 4mths - 3yrs
Parent Portal
Parent Information
About US
Employment Opportunities
SWIM SHOP

Special Needs Swimmer ProfileProfile was designed by Dennis Developmental Center