Special Education Services Swim Information Form printable pdf download

Special Education Services Swim Information Form

South Bend Community School Corporation

Special Education Services

Swim Information Form

Student Name: __________________________________Grade:__________________ Date: ________________

School:_______________________________________ Teacher Name:__________________________________

Emergency Phone Numbers:_________________________ cell:________________________________________

Parents/Guardian:_____________________________________________________________________________

Disability:____________________________________________________________________________________

Other Medical Information:______________________________________________________________________

___________________________________________________________________________________________

Medications:_______________________________________________________________________________

___________________________________________________________________________________________

Bathroom:

Independent

Not Independent

Swimming Experience:________________________________________________________________________

___________________________________________________________________________________________

Life Jacket Required:

Yes

Large Pool recommended:

Yes

Students Goals to work on:______________________________________________________________________

___________________________________________________________________________________________

Behavior Intervention Plan:

Yes

(attach if yes)

Health Plan:

Yes

(attach if yes)

8/19/12

Special Education Services Swim Information Form