Your Dancer's Name
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First Name
Last Name
Dancer's Birthdate
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MM
DD
YYYY
Your Name
*
First Name
Last Name
Your Relationship to Dancer
*
Your Email Address
*
Your Phone Number
*
(###)
###
####
Mailing Address for your Dancer
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please Select Your Family's First Choice
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Please note: this does not guarantee registration in the class. Registration will be confirmed by AIM Staff via Email before the session begins.
Please Select Your Family's Second Choice
*
Please note: this does not guarantee registration in the class. Registration will be confirmed by AIM Staff via Email before the session begins.
I am available for all the age-applicable class options:
Are you planning on using DDA Respite Funds to pay for these classes?
If using DDA funds, please include contact information for your DDA Case Manager below.
Dancers are encouraged to take class independent of caregivers; if your dancer has a medical need that necessitates your presence, please let us know you plan to stay?
What kind of music/musical artist does your dancer like to listen to? Do they have a favorite song?
Does your dancer use any mobility equipment such as a wheelchair, walker, etc.? If yes, please describe.
How might your dancer express their needs? (water, bathroom, rest, etc.)
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Is your dancer independent in the bathroom? If not, please share what staff needs to know to provide the best support.
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Is there anything teachers ought to know about your dancer to help keep them and fellow dancers safe while in class?
Does your dancer have any medical conditions? If yes, please share what staff will need to know to help your dancer in class.
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Does your dancer have any sensitivities? What, if anything, helps?
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Please share a bit about your dancer's school setting, if applicable.
*
Does your child work with an aide in class? Is your child in a self-contained classroom or part of an inclusion model at their school? What does your child like best about school?
How does your dancer show they are getting dysregulated, overwhelmed, or distressed? What, if anything, helps?
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What do you think your dancer will enjoy most about dance class? What might be more challenging for your dancer?
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What do you hope your dancer gains from this class experience?
Lastly, please share anything else you would like us to know about your dancer that will help us support them for a positive class experience.
We would especially love to know about anything related to physical, medical, intellectual, sensory, social-emotional, or behavior-related disabilities or sensitivities.
Zip Code
*
Which of the following best represents your Dancer's race?
*
Please check all that apply
If Other, please specify
Does your Dancer identify as Hispanic/Latinx?
*
What Language do you prefer to speak at home?
*
If Other, please specify
What Gender does your Dancer identify as?
*
If Self-describes in another way, please specify
