Child's Details

Child Name*

Child Date of Birth*

Child Gender*

Child Address (including postcode)*

Child Diagnosis. If no diagnosis please put as much information as you can*

What is your child working on during their on-land physiotherapy?*

Have you accessed hydrotherapy or swimming with your child in the past? If yes, what was your experience/what is their level of water confidence.*

Please complete the next two questions with as much information as you can. Please include as much information as possible about their goals and areas of development. The information you give will help with the selection criteria process.

How do you think your child could benefit from Hydrotherapy?*

What is the one key thing you would like your child to achieve by the end of their Hydrotherapy course?*

Can you explain how your child fulfils the Essential Inclusion Criteria?* (This should have been emailed to you, but if not you can find it on the website at https://www.littlehiccups.co.uk/hydrotherapy)

Parent/Carer Details

Please enter details of the parent supporting the child in the pool

Parent/Carer name*

Parent/Carer Date of Birth*

Parent/Carer Tel Number*

Parent/Carer email*

Alternative emergency contact and number*

Support Needs

Will your child need any of the following:

Hoist (please bring your own slings if you can)
Disabled Changing table
Help with walking

How will your child enter the pool:

Hoist (please bring your own slings if you can)
Pool Chair
Walk via steps
Sitting on the side
Carried by parent

Medical Conditions

Please let us know if you or your child have any of the following medical conditions or problems. Please complete for the child and also the parent/carer supporting the child in the pool.

Will be unable to enter the pool:

1. Acute vomiting or diarrhoea:
Child
Parent/Carer

2. Medical instability following an acute episode such as stroke, DVT, BP problems:
Child
Parent/Carer

3. Chlorine/Bromine allergy:
Child
Parent/Carer

4. Resting angina:
Child
Parent/Carer

5. Shortness of breath at rest:
Child
Parent/Carer

6. Uncontrolled heart failure:
Child
Parent/Carer

7. Weight in excess of evacuation equipment limit (21 stone/127kg):
Child
Parent/Carer

Hydrotherapy may be considered after a risk analysis:

8. Acute systemic illness:
Child
Parent/Carer

9. Irradiated skin during course of radiotherapy:
Child
Parent/Carer

10. Known aneurysm:
Child
Parent/Carer

11. Open infected wounds:
Child
Parent/Carer

12. Poorly controlled epilepsy:
Child
Parent/Carer

13. Unstable diabetes:
Child
Parent/Carer

Precautions:

14. Fear of water:
Child
Parent/Carer

15. Behavioural problems:
Child
Parent/Carer

16. Bowel and bladder disorders or incontinence of urine or faeces:
Child
Parent/Carer

17. Epilepsy:
Child
Parent/Carer

18. Haemophilia:
Child
Parent/Carer

19. Widespread MRSA:
Child
Parent/Carer

20. Hypotension:
Child
Parent/Carer

21. Renal Failure:
Child
Parent/Carer

22. Poor skin integrity:
Child
Parent/Carer

23. Pregnancy (if water temperature less than 35 degrees):
Child
Parent/Carer

24. Contact lenses or conjunctivitis:
Child
Parent/Carer

25. Hearing aids:
Child
Parent/Carer

26. Impaired sensation/vision/hearing:
Child
Parent/Carer

27. Invasive tubes in situ:
Child
Parent/Carer

28. Dizziness or blackouts:
Child
Parent/Carer

29. Spinal cord or neck problems:
Child
Parent/Carer

30. Kidney disease:
Child
Parent/Carer

31. Blood pressure problems:
Child
Parent/Carer

32. Osteoporosis:
Child
Parent/Carer

33. Recent fractured bones:
Child
Parent/Carer

34. Recent surgery:
Child
Parent/Carer

35. Other medical problems:
Child
Parent/Carer

If yes to any of the above, please give details below:

Please give details of any medication you or your child are currently taking::

Slot Date Preference

Please let us know if you have a preference of dates. You can select more than one option. Please leave blank if no preference.
This cannot be guaranteed but we will try to fulfil all requests.

Date preference

Slot Time Preference

Please let us know if you have a preference of times. You can select more than one option. Leave blank if no preference:
This cannot be guaranteed as factors such as use of slings/changing rooms and a mixture of ability in the pool will take precedence. But we will try to fulfil all requests.

Time slot preference

Any other comments:

Support in the water

We ask parents/carers to support their child in the water. However, there are a few reasons why you may not be able to. Please contact us on info@littlehiccups.co.uk if you are unsure and have any questions. Please let us know so if needed we are able to source volunteers to ensure numbers remain at safe levels.

Name/Names of people supporting the child in the water*

I am able and willing to be in the water with my child:
YesNo

Photo permissions

I give permission for Little Hiccups to take photographs and / or video of my child.

I grant Little Hiccups full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the group’s aims. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases and funding applications.

You have the right to opt out at any time.

I am happy for photos and video of my child to be taken:
YesNo

Electronic Signature

By submitting this form, I certify that the above information is correct, and I agree to promptly communicate any future changes to the above prior to use of the Hydrotherapy pool.

I give my consent for my son / daughter to participate in the pool / hydrotherapy sessions.

I also confirm that to the best of my knowledge (unforeseen circumstances aside) I will be able to attend all sessions.

Please keep in mind that all children must be supervised by their parent/carer at all times.