Swim Lesson Medical Information Form

Your child’s swim instructor has thirty minutes, a class of other children, wet hands and no chart. Everything they need fits on one sheet: what your child has, what it looks like when something goes wrong, where the medication is right now, and who to call. Fill this in, hand a copy over before the first lesson, and keep a second copy in the swim bag.

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📝 Start Here — How to Use This Form

  • Hand it over before lesson one, not on the day something happens. Telling the instructor at the moment your child starts coughing is too late for them to have set up the class differently.
  • Give a copy to more than one person. The instructor in the water, the front desk, and the lifeguard on duty. Ask where the copy will be kept and whether substitutes get it.
  • Re-do it every session and every instructor change. Swim school staff turn over between terms, and a form handed to someone who left in March protects nobody in September.
  • It goes with your doctor’s written plan, not instead of it. A written asthma action plan, diabetes care plan or seizure action plan from your child’s doctor is the clinical document. This sheet is the poolside translation of it.
  • Write in plain language, not diagnosis codes. “If she is coughing and cannot finish a sentence, get her out and give the blue inhaler in the front pocket” is more useful than any medical term.
This form is a communication tool, not medical advice. Everything you write on it should come from your child’s own pediatrician or specialist — they know your child’s severity, triggers, medication and clearance. Fill it in after that conversation, not instead of it.

👤 1. Child, Program and Contacts

Child’s name: ______________________
Age / date of birth: ______________________
Swim school & class: ______________________
Instructor’s name: ______________________
Parent / guardian: ______________________
Phone (during lessons): ______________________
Second contact & phone: ______________________
Doctor / specialist & phone: ______________________
Allergies (including medication): ______________________
Medical ID worn in the water? Yes / No
Date given to the program: ______________________
Review / re-issue date: ______________________

🩺 2. The Condition, in Six Lines an Instructor Can Act On

Fill in the right-hand column in your own words. If your child has more than one condition, use a second copy of this sheet rather than crowding one

What the instructor needsWhy it matters in the waterYour child
The condition, in one sentencePlain language beats a diagnosis name. An instructor who has never met this condition still needs to act correctly on the first day______
What a normal lesson looks like for this childStaff cannot spot a change without a baseline. Tell them what tired, pink-cheeked and fine looks like for your child______
The first sign something is wrong — specific to your childWater hides the early signals. Coughing that will not settle, sudden clumsiness, going quiet, or a warning your child recognises themselves______
What you want done firstNearly always: get them out of the water, then treat. Write the order you want, not just the treatment______
Where the medication or supplies are, right nowOn the deck within arm’s reach — not in the car, not at home, not locked behind the front desk______
Who to call, and when to call 911Name the point at which you want emergency services called without waiting for you to answer the phone______

✅ 3. The Five Things Every Instructor Must Be Told

  • The condition and how severe it is for this child. “Mild, and she has not needed the inhaler since spring” and “three hospital visits this year” call for different levels of vigilance.
  • The triggers. Cold water, a long set without a break, a poorly ventilated indoor pool, going too long without food, an unfamiliar routine, a whistle.
  • Where the medication is kept. Point at it. Then confirm the instructor can reach it in seconds without leaving the pool edge unwatched.
  • What the symptoms look like and what to do first. Most swim instructors hold first aid and CPR certificates, but that training does not cover asthma, hypoglycemia or seizure first aid specifically. A one-minute conversation fills that gap.
  • Who to call. Your number, a second contact, and the specialist. Confirm someone at the facility can reach a phone without leaving the water unwatched.
Ask one thing back. Does the instructor hold current CPR and first aid, and does that training include rescue breaths? Drowning is a breathing emergency, so a compressions-only course is not the right preparation for a poolside rescue.

📋 4. Condition Quick Reference — What to Say, What Stays on Deck

General education only. Your child’s doctor sets the actual plan — use this to know what to ask them, and what to pass on

ConditionTell the instructorOn deck, within reachWatch forAsk your doctor about
AsthmaSeverity, triggers, and that the pool trigger is usually chloramine gas in a poorly ventilated indoor pool rather than chlorine itselfRescue inhaler with spacer, plus a copy of the written asthma action planCoughing that will not settle, wheeze, chest tightness, unusual breathlessness after a setClearance to swim, and whether a dose 15–30 minutes before activity is right for your child
Type 1 diabetesThat exercise lowers blood sugar for hours, and that water hides the early signs of a low — so this child never swims aloneFast-acting carbs (glucose tabs or juice), meter or CGM, hypo kit, glucagon if prescribed, medical ID wornShakiness, sweating, confusion, weakness, or your child saying they feel “off” — out of the water and treat, then recheckTargets before swimming, how often to check during, the insulin pump plan in water, and delayed lows later that day
Epilepsy or seizuresThe seizure type, what one looks like, and that this child needs a designated adult within arm’s reach whose only job is themSeizure first aid steps in writing; emergency medication if prescribedYour child’s own warning sign or aura. In water: support the head, keep the face clear, move to the edge, get out, call for helpYour neurologist’s guidance, whether lessons should be one-on-one, and bathtub rules at home
Ear tubes or recent ear surgeryThat updated AAO–HNS guidance means most children with standard tubes can swim at the surface in a chlorinated pool without ear plugs — and what your ENT said for your childOnly what the ENT specified. Custom-molded plugs if they were prescribedEar drainage, ear pain, or muffled hearing after swimmingDiving and deep submersion, dunking games, lakes and ocean, and whether plugs are needed at all
Cast, splint or walking bootWhich kind it is. A standard plaster or fiberglass cast must stay completely dry; only a waterproof-liner cast is designed to get wet, and only with the orthopedist’s approvalThe cast care instructions. A waterproof cover is for showering — it is not a green light to swimWet or smelling padding, itching and rash underneath, a cast that has softened or lost its shapeWater clearance, and whether deck-side participation makes sense until the cast comes off
EczemaThe routine, and that the instructor does not need to comment on the skin. Barrier moisturizer 15–30 minutes before; rinse and re-moisturize within about five minutes afterFragrance-free moisturizer or ointment, a towel, and a rash guard if your child wears oneStinging or a new flare after a specific pool — useful information about that facility’s waterWhich product to use before and after, and whether one pool suits your child better than another
ADHD or high impulsivityThat the water risk is impulsivity — entering before the instructor is ready, leaving the wall, dashing toward the pool on arrivalNothing medical, unless medication is timed around the lesson. Ask about that timingGetting in ahead of the instruction, or losing the thread of a multi-step directionWhether medication timing affects the lesson, and whether a smaller class or private lesson is worth it
Autism or sensory differencesThe specific sensory triggers — echo, whistles, cold water, the smell — how your child shows distress, and any wandering riskWhatever your child uses to regulate: ear defenders on deck, a familiar towel, a visual scheduleShutdown or overwhelm rather than obvious protest, and any move toward the water outside lesson timeAdaptive or one-on-one programs, and the home water-safety layers that go with a wandering risk
Do not let the list above override your own doctor. Two children with the same diagnosis can need opposite plans. Where this sheet and your specialist disagree, the specialist wins — write their answer in the fill-in column and hand that over.

💊 5. Medication and Supplies on Deck

Fill this in at the pool, on the first day, with the instructor standing next to you

ItemWhere it is kept during classExpiry dateWho may give it
________________________
________________________
________________________
________________________
Check the expiry dates at the start of every session. A rescue inhaler or glucagon that expired over the winter is the same as no medication at all, and the swim bag is exactly where things go quietly out of date.

🚩 6. Stop the Lesson and Get Your Child Out

  • Breathing that does not settle with rest, wheeze, or a cough that keeps going once your child is out of the water.
  • Blue or grey lips, fingernails or skin around the mouth.
  • Confusion, unusual drowsiness, or an inability to answer a simple question. In a child with diabetes, treat this as a low until proven otherwise.
  • A seizure of any length. Support the head, keep the face above water, move to the edge, remove from the water, and get medical help — a seizure in water always warrants medical attention, even if the child seems fine afterwards.
  • Anything the parent wrote in the “first sign” line above. The parent knows this child; the sheet exists so the instructor does not have to guess.
If your child is unresponsive and not breathing normally. Get them out of the water, have someone call 911 and fetch the AED, then give two rescue breaths and start CPR at 30 compressions to 2 breaths. Drowning is a breathing emergency, which is why the breaths come first. Gasping does not count as breathing. This form is a memory aid, not a substitute for a hands-on infant and child CPR class.

❓ 7. Ask the Program Before You Enroll

  • May the medication stay on the deck within arm’s reach? Some facilities lock all medication at the front desk. For a rescue inhaler or fast-acting carbs that is the wrong place.
  • Does the instructor in the water hold current CPR and first aid — including rescue breaths? Ask to see the certification date, not just the claim.
  • Who is watching my child while the instructor is helping another one? This is the question a class ratio is really about.
  • Is a one-on-one or smaller class available, and what does it cost? For seizure disorders in particular, a designated adult within arm’s reach is the safeguard that makes swimming safe.
  • What is your written procedure if a child has a medical event in the water? A program that has one will say so immediately.
  • Will this form reach substitute instructors, and where will it be kept?
  • What temperature is the water, and how long is the in-water portion? Relevant for cold sensitivity, and for any child whose condition is affected by a long unbroken set.
  • Have your instructors taught a child with this condition before? “No, but tell us what we need to know” is a perfectly good answer. Vagueness is not.

✍️ 8. Doctor’s Clearance Record

Discussed with (name): ______________________
Date: ______________________
Cleared for: ______________________
Restrictions: ______________________
Written action plan attached? Yes / No
Next review date: ______________________
Bring the answer back in writing. “The doctor said it’s fine” is hard for a program to act on. A dated line naming what your child is cleared for, and what they are not, ends every subsequent argument at the front desk.

⭐ 9. The Line That Matters Most

  • A medical condition is a reason to be in swim lessons, not a reason to skip them. A child with asthma, diabetes, epilepsy, tubes or a cast will still be near water — at a birthday party, on holiday, at a friend’s house.
  • Some conditions raise the stakes rather than the restrictions. Seizure disorders in particular carry an elevated drowning risk, which is an argument for a dedicated adult within arm’s reach — not an argument for staying out of the water.
  • Supervision stays a layer, whatever the sheet says. No form, plan or medication replaces an adult who is watching, close, and not doing anything else.
  • Hand it over and keep going. The families whose children keep swimming are the ones who made the condition ordinary for the program — written down once, updated each term, never a surprise.
Why this is worth the ten minutes. Participation in formal swim lessons is associated with a large reduction in drowning risk for young children, and drowning remains a leading cause of death for children ages 1–4. The purpose of this form is not paperwork. It is to remove the reason a program might hesitate, and the reason a family might quietly stop going.

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Keep reading — the detail behind every row on this form.

The Form Is the Easy Part. The Lessons Are the Point.

A written sheet removes the reason a program hesitates and the reason a family quietly stops going. Participation in formal swim lessons is associated with a large reduction in drowning risk for young children, and drowning remains a leading cause of death for children ages 1–4.

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