Neverland Aquatics Online Registration

Registration

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Welcome to Neverland Aquatics where everyone can be successful in the water! All boxes with a red * are required and must be completed to enroll in services with us. This form helps us know how to best serve you and your swimmer. Once completed, you will receive a confirmation email with a link to your Parent Portal account which enables you to enroll in our services. If you have any questions, please contact us at schedule@adaptedswim.com. We look forward to splashing with you soon!

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Do you use a Funding Source? If none, say none.

Grade Level

Primary Care Doctor Name & Phone Number*

Does your student have a diagnosed or undiagnosed disability? Any medical conditions or allergies?*

Explain your student's mobility in and out of the water. *

Explain your students method of communication. What do they tend to do/say when they express upset?*

What teaching strategies does your student respond best to? What rewards do they enjoy working for?*

Does your student have sensory needs or sensitivities?*

What does a typical aquatic experience look like for your student? What do they do in the water?*

Any fear/anxiety about water?*

Past negative aquatic event?*

Any history of elopement?*

Any recurring behaviors?*

Anything else we should know?*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Do you use a Funding Source? If none, say none.

Grade Level

Primary Care Doctor Name & Phone Number*

Does your student have a diagnosed or undiagnosed disability? Any medical conditions or allergies?*

Explain your student's mobility in and out of the water. *

Explain your students method of communication. What do they tend to do/say when they express upset?*

What teaching strategies does your student respond best to? What rewards do they enjoy working for?*

Does your student have sensory needs or sensitivities?*

What does a typical aquatic experience look like for your student? What do they do in the water?*

Any fear/anxiety about water?*

Past negative aquatic event?*

Any history of elopement?*

Any recurring behaviors?*

Anything else we should know?*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Do you use a Funding Source? If none, say none.

Grade Level

Primary Care Doctor Name & Phone Number*

Does your student have a diagnosed or undiagnosed disability? Any medical conditions or allergies?*

Explain your student's mobility in and out of the water. *

Explain your students method of communication. What do they tend to do/say when they express upset?*

What teaching strategies does your student respond best to? What rewards do they enjoy working for?*

Does your student have sensory needs or sensitivities?*

What does a typical aquatic experience look like for your student? What do they do in the water?*

Any fear/anxiety about water?*

Past negative aquatic event?*

Any history of elopement?*

Any recurring behaviors?*

Anything else we should know?*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Do you use a Funding Source? If none, say none.

Grade Level

Primary Care Doctor Name & Phone Number*

Does your student have a diagnosed or undiagnosed disability? Any medical conditions or allergies?*

Explain your student's mobility in and out of the water. *

Explain your students method of communication. What do they tend to do/say when they express upset?*

What teaching strategies does your student respond best to? What rewards do they enjoy working for?*

Does your student have sensory needs or sensitivities?*

What does a typical aquatic experience look like for your student? What do they do in the water?*

Any fear/anxiety about water?*

Past negative aquatic event?*

Any history of elopement?*

Any recurring behaviors?*

Anything else we should know?*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Do you use a Funding Source? If none, say none.

Grade Level

Primary Care Doctor Name & Phone Number*

Does your student have a diagnosed or undiagnosed disability? Any medical conditions or allergies?*

Explain your student's mobility in and out of the water. *

Explain your students method of communication. What do they tend to do/say when they express upset?*

What teaching strategies does your student respond best to? What rewards do they enjoy working for?*

Does your student have sensory needs or sensitivities?*

What does a typical aquatic experience look like for your student? What do they do in the water?*

Any fear/anxiety about water?*

Past negative aquatic event?*

Any history of elopement?*

Any recurring behaviors?*

Anything else we should know?*

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

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Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

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