APPLICATION FORM FOR DOLPHIN ASSISTED THERAPY
The children have to be between 5 and 15 years old,
the children may not have any contagious illness,
the children may not have open wounds,
the children must be able to swallow water,
the children must be able to control their head
and the children may not be afraid of strange persons.
Children, who are not able to walk, cannot weigh more than 20 kilograms.

More info: https://bit.ly/2IYB3Uu

Fundación Aqualandia - Mundomar
Today’s Date
MM
/
DD
/
YYYY
Child's full name *
Birthdate *
MM
/
DD
/
YYYY
Birthplace *
Full Address *
Telephone, fax *
Email *
Height and weight *
Diagnosis *
Name and address of school *
Name and address of doctor or permanent therapist *
Brothers/ sisters *
Required
How many?
Does the child like animals, which ones? *
Does the child like to swim in water? *
Does the child have a visual disorder? *
Is the child hard of hearing? *
Is the child incontinent? *
Native language *
Reason for applying to the program *
Did the child already attend a dolphin assisted therapy (in Mundomar or another centre)? *
Present state of health *
Post health problems *
Treatments (medication, operations, therapies) *
Experience with animals (positive/ negative)
Experience in the water (positive/ negative): *
Can the child maintain head control? *
Can the child walk? *
Can the child extend arms/ grasp objects? *
Can the child make and maintain eye contact? *
Will the child interact with others? *
Does the child experience anxiety when separated from parents? *
Does the child acclimate to changes in the environment? *
Is the child aggressive with others? *
Does the child exhibit any self injurious behaviour (head banging, biting, etc.)? *
Does the child babble or vocalise (make noises)? *
Does the child use words or phrases? *
Is language spontaneous (initiated independently)? *
Does the child respond to his/ her name? *
Does the child follow simple directions? *
Is the child aware of his/ her environment? *
Recomendations
Please send child's foto, history, latest school records, latest medical information, comments or any pertinent information regarding your child that would be helpful to the therapist.

Please confirm that this application has been presented with the best of your knowledge and with the agreement of the patient or responsible person (parents, doctor, therapist) and that our medical staff is permitted to receive this and other information as required. All details remain confidential.

The dolphin assisted therapy in MUNDOMAR is free of charge. Mundomar will not be responsible for any physical harm or damage to the child and its family within the park.

Upload your files
When would you like to come to the therapy: (one week, Mon. –Sat., from May till end of October) Put the start day of the week *
MM
/
DD
/
YYYY
Substitution week (Put the start day of the week) *
MM
/
DD
/
YYYY
Name and relationship to the child of person filling out this application *
Data Protection Policy
I have read and I agree to the Data Protection Policy *
Required
Fundación Aqualandia - Mundomar Delfinoterapia
Sierra Helada s.n. - Rincon de Loix
E- 03503 Benidorm (Alicante)
España
Tel: (0034) 96 586 91 01/ 02/ 03
Fax: (0034) 96 586 88 89
E-mail: Mundomar@mundomar.es
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service