AQUATIC PROGRAM APPLICATION
(Includes release form and diagnostic verification form)

 Name: _____________________________________           Age: _____      Birthday __________

Address: _____________________________________________________________________________

Phone: ______________________________  Work or Cell Phone: ______________________________

Email address: _____________________________________________________________________

►Class I am interested in: ______________________________    Time: ________________

I am able to dress, shower, exit/enter pool environment without assistance _____Yes       _____No

If assistance is required, I will be able to provide someone to assist me _____Yes            _____No

I am independent with mobility via ambulation or device for a minimum of 100 feet _____Yes   _____No

I am independent with toileting needs?    _____Yes    _____No  

My skin is free of open wounds, tears or rashes? _____Yes        _____No

I am aware of the safety precautions that are required within a pool environment? _____Yes_____No

I learned about the Aquatics Program via _________________________________________________.

Release Form

I understand and agree that there are risks, both foreseeable and unpredictable, associated with any exercise program. I am aware of these risks and agree that my participation is at my own risk. If my application for the Aquatics Program is accepted, and I am permitted to participate in this program.  I do hereby, for myself, my heirs, executors and administrators, waive, release, and forever discharge any and all rights and claims for damages that I may have or that may hereafter accrue to me arising out of or in any way connected with my participation in this or any future programs.  I also represent and warrant that I have been advised to seek consultation from my doctor about whether I can safely participate in this program and whether there are precautions or limitations to my participation.

_______________________________________      __________________
Signature                                                                                   Date

Diagnostic Verification Form – for Applicant to sign

I give permission to Dr. ___________________________________ to complete this form.     

_______________________________________                ___________________________
Signature                                                                                                              Date

FOR PHYSICIAN TO COMPLETE:

Your patient is interested in a warm water exercise program consisting of range-of-motion, muscle strengthening, and endurance-building activities. Persons with total joint replacements, multiple joint involvement or moderate to severe joint involvement may require individualized instruction by a physical or occupational therapist. If your patient requires this instruction, you may want to refer them to a therapist prior to participation in the program.

My patient, named above, has the following type of disease/condition: _____________________
_____________________________________________________________.

Limitations/Precautions: ________________________________________________________________________.

 ______________________________________                ____________________________
Physicians signature                                                                                          Date

YOU MAY RETURN VIA MAIL TO AQUATIC THERAPY,  PO BOX 571207, WINSTON-SALEM, NC 27157-1207 OR BY FAX TO: DEBBIE DRAYTON 336-713-8193