Summer Paddling Registration

Who is completing this form for the student? *

I am the person taking lessons.

I am a parent, guardian, etc., of the student.

Student Name *

First Name

Last Name

Landline Contact Phone

(###)

###

####

Mobile Contact Phone

(###)

###

####

Student Birth Date

MM

DD

YYYY

Date of Diagnosis or Injury *

MM

DD

YYYY

Father or Guardian Name (if minor applicant)

First Name

Last Name

Mother or Guardian Name (if minor applicant)

First Name

Last Name

Business Telephone

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Physician Name

First Name

Last Name

Physician Phone

(###)

###

####

Are You Currently receiving Therapy Services?

Check all that apply

Physical Therapy

Speech Therapy

Occupational Therapy

Therapist Name

First Name

Last Name

Day(s) of Week You Are Interested in Taking a Paddling Lesson

All lessons are by appointment only and will be confirmed by phone

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How Does the Student Communicate?

Verbally

ASL

Pictures

Augmentative Communication Device

Other Assistive Technology