Apply for Aquatic Mobility

Apply for Aquatic Mobility

Apply for Aquatic Mobility

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Apply here for a spot in Holy Angels' Aquatic Mobility Program. Sessions are one-on-one, therefore limited spacing is available. Applications will be reviewed by Health & Wellness Services.

Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Client's Name*
Client's Age
Please select the correct choice for pricing*
My Client is..
- A resident at Holy Angels
- A resident with Cerebral Palsy at Holy Angels
- A Client in the AngelWorks Day Program
- A New Client for Holy Angels
Can your client swim?*
If no, will they be able to swim using a flotation device?
Has your client received Aquatic Mobility in the past?*
Is your client currently partaking in Physical Therapy?*
If yes, where?
Does your client have any fears/triggers with water or fears of going under water? Please explain.*
Does your client have behaviors?*
If yes, please explain what they are and what triggers them.
Who will accompany your client during their session?
e.g. Direct Service Professional, Guardian, etc.
Please list any other important information our Exercise Physiologist needs to know in order to give your client the best one-on-one session.
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May 2023