Breathing Chest Asthma Requires oxygen Other difficulties infections Heart Existing Surgically Stable problems condition repaired Tonic/ tonic Care plan attached Well Absence clonic/ Epilepsy Needs medication controlled seizure unclassified after minutes seizures Blood High Low pressure Additional Gastrostomy Gastrostomy NG Tube Tracheostomy tubing button peg Hearing/ Hearing Registered visual Grommets Glasses aids/device blind difficulties Muscle tone High Low Spasms Dystonia Skin Skin Eczema Chlorine allergy Verrucae conditions infection Weight in Diabetes Incontinence Use of thickeners excess of 160kg Other Swallowing Other difficulties If any family members or person attending the Hydro Pool sessions have any medical problems or health condition, please specify Family member Medical problem / Health condition Hydrotherapy Pool Session: If you would like a Hydrotherapy slot, please fill in the section below with your preferred dates and times. Hourly session run throughout the day and are age related. You can book a maximum of three sessions during the Summer Scheme. Children’s sessions: 9.00-10.00; 10.00-11.00; 11.00-12.00; 12.00-13.00 Young people’s sessions: 14.00-15.00; 15.00-16.00 Session Date Time Name and age of children and number of adults Preference attending in the water Example 11/8 9 - 10am 5 - Mum Jane, Dad Joe, Jessica 5, Jenny 15 and Jack 3 Choice 1 Choice 2 Choice 3
Breathing difficulties Asthma Chest infections Requires oxygen Other Heart problems Existing condition Surgically repaired Stable Epilepsy Well controlled Absence seizure Tonic/ tonic clonic/ unclassified seizures Care plan attached Needs medication after minutes Blood pressure High Low Additional tubing Gastrostomy button Gastrostomy peg NG Tube Tracheostomy Hearing/ visual difficulties Grommets Hearing aids/device Glasses Registered blind Muscle tone High Low Spasms Dystonia Skin conditions Eczema Skin infection Chlorine allergy Verrucae Other Diabetes Incontinence Weight in excess of 160kg Use of thickeners Swallowing difficulties Other If any family members or person attending the Hydro Pool sessions have any medical problems or health condition, please specify Family member Medical problem / Health condition Hydrotherapy Pool Session: If you would like a Hydrotherapy slot, please fill in the section below with your preferred dates and times. Hourly session run throughout the day and are age related. You can book a maximum of three sessions during the Summer Scheme. Children’s sessions: 9.00-10.00; 10.00-11.00; 11.00-12.00; 12.00-13.00 Young people’s sessions: 14.00-15.00; 15.00-16.00 Session Preference Date Time Name and age of children and number of adults attending in the water Example 11/8 9 - 10am 5 - Mum Jane, Dad Joe, Jessica 5, Jenny 15 and Jack 3 Choice 1 Choice 2 Choice 3
SwimandPlay2016.docx