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Permission to Swim 2020-2021

Please complete the form below. Required fields marked with an asterisk *

Contact Information

Student First Name*

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Student Last Name*

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Phone*

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Address*

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Birthdate*

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1. ANY VISUAL OR HEARING IMPAIRMENTS SUCH AS TUBES IN THE EARS, OR CHRONIC EAR INFECTIONS? EXPLAIN.*

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2. ANY PHYSICAL OR MOTOR IMPAIRMENTS SUCH AS A WHEELCHAIR OR CP?*

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3. ANY RESPIRATORY OR CIRCULATION PROBLEMS SUCH AS A HEART MURMUR OR ASTHMA? (STUDENTS WITH CURRENT TRACHEOTOMIES ARE EXCUSED FROM SWIM CLASS).*

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4. ANY ALLERGIES, ESPECIALLY TO CHLORINE?*

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5. A HISTORY OF SEIZURES?(WHAT TYPE, SEVERITY, FREQUENCY)*

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6. ANY OTHER LIMITATIONS OR IMPORTANT INFORMATION THAT THE SWIM STAFF SHOULD KNOW?*

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7. IF YOUR CHILD HAS DOWN’S SYNDROME, WERE THE RESULTS OF THEIR ATLANTOZXIAL DISLOCATION TEST, POSITIVE OR NEGATIVE?*

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Positive

Negative

My child does not have Down Syndrome

8. Permission to swim: *

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Yes, my child may participate in swim class for the 2019-2020 school year.

No, my child MAY NOT participate in swim class for the 2019-2020 school year.

By typing your name below, you are agreeing to an electronic signature of this document.*

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