Boulder Ballet Adaptive Dance Program Intake Form
Please complete this brief intake form. This information with help with class preparation and instructor education as we strive to make this a therapeutic and fun experience for dancers of all abilities! On December 16, 2018, dancers for the program will also have an evaluation session with one of the physician directors to evaluate for specific adaptations needed. For any questions, please email amy@boulderballet.org or call 303-443-0028 extension 206.

We respect your and your child's privacy and medical information collected. Information collected via this form and via the in-person medical evaluation will be used to provide the dancer the best experience possible with our adaptive dance program. If you would prefer to fill this form out via paper and pen and email it to us, please print this page and email a copy to the above email address. Thanks!

Dancer's name (first and last) *
Your answer
Dancer's age: *
Your answer
Dancer's date of birth: *
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Parent(s)/guardian(s) name(s): *
Your answer
Phone number (Parent/guardian): *
Your answer
Email address (Parent/guardian): *
Your answer
Emergency Contact (Please furnish the name of someone outside the home who can be contacted in an emergency if the legal guardian(s) of the child cannot be reached): *
Your answer
Emergency Contact phone number: *
Your answer
Dancer's primary care physician name: *
Your answer
Dancer's primary care physician phone number: *
Your answer
Dancer's primary medical diagnosis/diagnoses affecting impairment: *
Please be specific (e.g. cerebral palsy, autism spectrum disorder, Down syndrome, spina bifida, etc.)
Your answer
Does the dancer have any other medical diagnoses or concerns (e.g. asthma, seizure disorder, heart disease, vascular disease, etc)? If so, please list these: *
Your answer
Please list dancer's past surgical procedures, if any (including approximate dates): *
Your answer
Please list any special medical/health precautions (include past and present seizure activity, activity restrictions made by a physician, allergies, etc.): *
Your answer
Please list any medications the dancer takes (including dosage, frequency, and reason for medication): *
Your answer
Dancer's height (in feet/inches): *
Your answer
Dancer's weight (in pounds): *
Your answer
Dancer's shoe size: *
Your answer
Current therapies dancer is receiving: *
Current adaptive devices or equipment being used: *
Your answer
Level of assistance dancer requires with everyday activities: *
Approximate distance dancer is able to walk (please note if this is with or without assistance/equipment): *
*If not able to walk, you may write this in as well.
Your answer
Please provide a brief description of the dancer's PHYSICAL impairments, if any: *
Your answer
Please provide a brief description of the dancer's COGNITIVE/COMMUNICATION impairments, if any. List any pertinent information about the dancer’s ability to understand what is said to him/her; ability to express wants/needs, including any techniques or gestures used, etc. *
Your answer
If the dancer has any behavioral issues that may require special techniques or intervention from staff or volunteers, please describe below: *
Your answer
Please describe in detail any special needs the dancer might have in managing his/her bladder and/or bowel during dance sessions: *
Your answer
Has the dancer had experience participating in any other sports of physical activities in the past (including any previous dance programs)? If so, please list these. *
(It is okay if the dancer has not had any prior experience with other dance programs or other activities. We welcome dancers of all levels of experience!)
Your answer
Does the dancer participate in any other sports or physical activities currently? If so, please list these. *
Your answer
Any other relevant information you think the medical directors or dance instructors should know? *
Your answer
Is the dancer available to attend the evaluation with the physician director on Sunday, December 16, 2018 during the day for 30 minutes? *
If the dancer is not available, they will have to arrange for an evaluation with the physician director prior to the first dance session in January.
Your answer
If you would like to be considered for financial assistance for the $25 program registration fee, please select here:
PARENT/GUARDIAN CONSENT: I/we understand that information provided in this application and documentation about my child’s participation in the Boulder Ballet Adaptive Dance program will be shared with volunteers and staff working with the Boulder Ballet Adaptive Dance program. I/we agree to follow the protocol for Boulder Ballet's Adaptive Dance program and participate in the program as described, including: promoting the child’s cooperation and acceptance of dance instruction, adhering to attendance guidelines, and for payment of the dance program fee (unless receiving financial assistance). Please electronically sign by typing your name (parent/guardian) and the date below: *
Your answer
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