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BRONX SWIM LESSONS update
MANHATTAN SWIM LESSONS
SPECIAL NEEDS INTAKE FORM
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registrations@reachacademy.nyc

Special Needs Intake Form

PARENT'S FIRST AND LAST NAME

PARENTS CELL PHONE NUMBER (number we can send text)

PARENT EMAIL

CHILD'S FIRST AND LAST NAMES

CHILD'S DATE OF BIRTH

DESCRIBE YOUR CHILD'S SPECIAL NEEDS DIAGNOSIS

WHAT IS THE LEVEL OF DIAGNOSIS FOR YOUR CHILD

IS YOUR CHILD VERBAL

HOW WELL DOES YOUR CHILD FOCUS IN CLASS SEETTINGS

WHAT IS YOUR CHILD'S COMFORT WITH THE WATER

DOES YOUR CHILD HAVE ANY FEARS OF WATER OR EXTREME SENSORY ISSUES (PLEASE EXPLAIN)

PLEASE PROVIDE US WITH ANY PERTINENT INFORMATION THAT WILL HELP US

HOW DID YOU HEAR ABOUT US?

Thanks for submitting, we will get back to you within 24 hours

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