Enrollment Checklist - Fee Based Ymca Of Silicon Valle Page 12
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12YMCA of SiliCon VAlleY
Special Needs Inclusion Intake
Participant’s Name
Birth date
Age
School
Grade
Teacher
Parent/Guardian’s Name
Address
City
Zip
Home #
Cell #
Email
What is the participant’s clinical diagnosis?
What are the special needs for participant?
What tendencies does the participant display?
What stimulations is the participant sensitive to?
How can we communicate with the participant?
is there anything we can reinforce with the participant that is happening in school or home environment?
What are the participant’s likes and dislikes pertaining to this program?
Are there any personal care issues we need to know about?
Does the participant require administration of medication during this program?
Does the participant have seizures?
Does the participant enjoy the water?
Do you have any concerns?
What are your expectations for the participant in this program?
What special accommodations does your child require?
Comments:
Taken by:
¨ Swim Lessons
¨ Day Camp
¨ CC / ASEP
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