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2021-2022 Form: Permission to Swim

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

Contact Information

Student First Name*

Answer Required

Student Last Name*

Answer Required

Phone*

Answer Required

Address*

Answer Required

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 (e.g., Wheelchair, Cerebral Palsy)*

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 2021-2022 school year.

No, my child MAY NOT participate in swim class for the 2021-2022 school year.

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

Answer Required