Adaptive Aquatics Waitlist Form

This form is will help us to match up our swimmers with our instructors. Please take a moment to answer the questions below.

Adaptive Swim lessons are for members of our community with Special Needs.

**Please note: this is NOT a registration form and by filling this form out it does NOT guarantee your spot in lessons.**

If you have any questions, please reach out to Bridget via the contact information below.

Thank you!

Bridget Jones, Director of Kehillah Special Needs Programs

bjones@springfieldjcc.org

Parent/Guardian's Info

Please select the swimmer's availability from the following options:

Additional Questions

Our Adaptive Lessons have been 1:1 private lessons in the past and we've had requests for small group private lessons. Select which you would be interested in registering for:

30 minute Private lesson (1 on 1) 30 minute Small group (2-3)

Have you filled out the Springfield JCC Adaptive Aquatics Intake Form in the last 12 months? If no, Leonor will email you an Intake Form to be completed at the email listed above.

Yes No

Additional information you would like to share in regard to adaptive swim lessons? Please include your child's diagnosis and any goal(s) you may have.

Adaptive Aquatics Waitlist Form

Swimmer's Info

Parent/Guardian's Info

Please select the swimmer's availability from the following options:

Additional Questions

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