Interval Workout Participants Survey
Hello Parents, to better serve each participant abilities, we ask that you fill this short form. Thank you
Email address *
1. Participant First and Last Name *
Your answer
2. Participant age *
Your answer
3. Participant can express him/herself in whole sentences *
Very good
4. Participant can understand and follow visual demonstration *
5. Participant is able to remember multiple-step instructions *
Probably Not
Definitely Yes
6. Participant has difficulty acquiring new motor skills *
7. Participant Eye/Hand coordination level *
8. Balance problems; for instance, has difficulty standing on one leg *
9. Difficulty handling, assembling and manipulating small objects *
10. Often has difficulty sustaining attention in tasks or play activities *
11. Able to follow verbal directions with modeling independently? *
If No - please explain
Your answer
12. Does the participant has any physical limitation? *
If YES - please explain
Your answer
12. I confirm that my child is in good health and can take part in an Interactive Workout at interval. I understand that; if any medical changes occur with my child health. I am required to provide Maagalim a physician medical authorization in order to participate in Maagalim activities. *
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