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New Horizon School (BVIU #27)
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Parent Presentation: 12/15/2020
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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
*
Answer Required
Student Last Name
*
Answer Required
Phone
*
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Address
*
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Birthdate
*
Answer Required
1. ANY VISUAL OR HEARING IMPAIRMENTS SUCH AS TUBES IN THE EARS, OR CHRONIC EAR INFECTIONS? EXPLAIN.
*
Answer Required
2. ANY PHYSICAL OR MOTOR IMPAIRMENTS SUCH AS A WHEELCHAIR OR CP?
*
Answer Required
3. ANY RESPIRATORY OR CIRCULATION PROBLEMS SUCH AS A HEART MURMUR OR ASTHMA? (STUDENTS WITH CURRENT TRACHEOTOMIES ARE EXCUSED FROM SWIM CLASS).
*
Answer Required
4. ANY ALLERGIES, ESPECIALLY TO CHLORINE?
*
Answer Required
5. A HISTORY OF SEIZURES?(WHAT TYPE, SEVERITY, FREQUENCY)
*
Answer Required
6. ANY OTHER LIMITATIONS OR IMPORTANT INFORMATION THAT THE SWIM STAFF SHOULD KNOW?
*
Answer Required
7. IF YOUR CHILD HAS DOWN’S SYNDROME, WERE THE RESULTS OF THEIR ATLANTOZXIAL DISLOCATION TEST, POSITIVE OR NEGATIVE?
*
Answer Required
Positive
Negative
My child does not have Down Syndrome
8. Permission to swim:
*
Answer Required
Yes, my child may participate in swim class for the 2020-2021 school year.
No, my child MAY NOT participate in swim class for the 2020-2021 school year.
By typing your name below, you are agreeing to an electronic signature of this document.
*
Answer Required
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