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! Prior to the first dance class on 1/26/20, dancers new to the program will also have an evaluation session with one of the physician directors to evaluate for specific adaptations needed - Boulder Ballet will call you to schedule this appointment. 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!

Classes will take place at the Dairy Arts Center in Boulder, CO on Sundays from 11:00-11:45am. The dates for our winter/spring session will be: January 26th, February 9th and 16th, March 8th and 15th, April 5th and 19th, and May 17th (final class with performance).

DEADLINE for all dancer applications: 1/6/20
Dancer's name (first and last) *
Dancer's age: *
Dancer's date of birth: *
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Parent(s)/guardian(s) name(s): *
Phone number (Parent/guardian): *
Email address (Parent/guardian): *
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): *
Emergency Contact phone number: *
Dancer's primary care physician name: *
Dancer's primary care physician phone number: *
Dancer's primary medical diagnosis/diagnoses affecting impairment: *
Please be specific (e.g. cerebral palsy, autism spectrum disorder, Down syndrome, spina bifida, etc.)
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: *
Please list dancer's past surgical procedures, if any (including approximate dates): *
Please list any medications the dancer takes (including dosage, frequency, and reason for medication): *
Dancer's height (in feet/inches): *
Dancer's weight (in pounds): *
Dancer's shoe size: *
Current therapies dancer is receiving: *
Required
Current adaptive devices or equipment being used: *
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.
Please provide a brief description of the dancer's PHYSICAL impairments, if any: *
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. *
If the dancer has any behavioral issues that may require special techniques or intervention from staff or volunteers, please describe below: *
Please describe in detail any special needs the dancer might have in managing his/her bladder and/or bowel during dance sessions: *
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!)
Any other relevant information you think the medical directors or dance instructors should know? *
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: *
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