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Autism Family Open Swim 5:00-7:00 pm - For families with children with Autism - $5.00 per family to be paid the night of open swim. The whole family is welcome to attend and swim. Parents should bring suits to be in the water with their children. We have staff supervising, but parents are responsible for their children. We will order pizza based on the families checked in at 5:30 pm. If you are coming later and want pizza, please call us so we get some pizza for your family. If you decide not to attend, a phone call informing us will also be appreciated.
Event:
Start Date/Time:
End Date/Time:
Fee per Family:
Room:
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Family Information
First Name:
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Last Name:
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Type
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Father
Grandfather
Grandmother
Guardian
Mother
Other
Parent
Stepfather
Stepmother
Student
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
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City:
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State:
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AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
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KY
LA
MA
MD
ME
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MO
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ND
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NJ
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NY
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OH
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OR
PA
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TN
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VA
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WA
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Zip:
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Emergency Contact Info
Add New Student #1:
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Student's First Name:
*
Last Name:
*
Student Gender:
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Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
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Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #3:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #4:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Questions/Options:
Please list the names of the children and their age attending from your family.
*
Please list the names of the adults attending from your family.
*
We serve cheese pizza. Please indicate how many people will be eating pizza. We order pizza based on families checked in at 5:30. If you are coming later, please call so we have pizza for your family.
*
Additional Information:
Supervision of Children
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I understand that all children, regardless of swimming ability, need to be directly supervised by their parent or some other responsible adult. This means parents need to be in the water with their children. The open swim night is for families to enjoy the facility for open swimming. It is not an opportunity for lessons.
I've read the above and agree.
Fee
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I will pay $5.00 on the night of the event for our family.
I've read the above and agree.
Swim Diapers
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I understand that if I have any children that are not 100% toilet trained, that they will wear a permanent reusable swim diaper. I understand that Little Waves has these available on site and I may purchase one there.
I've read the above and agree.
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