Special Education Services Swim Information Form

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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
No
Large Pool recommended:
Yes
No
Students Goals to work on:______________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Behavior Intervention Plan:
Yes
No
(attach if yes)
Health Plan:
Yes
No
(attach if yes)
8/19/12

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