Shine
Please complete this form with as much detail as possible so that our staff will be able to understand the level of support your child may need. A member of our staff will be in contact with you shortly. We want to make sure your child will SHINE at Creekside.
Child's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
-
Month
-
Day
Year
Date
School Attending
Current Grade
Mother/Guardian Name
First Name
Last Name
Mother/Guardian Email
example@example.com
Mother/Guardian Phone
-
Area Code
Phone Number
Father/Guardian Name
First Name
Last Name
Father/Guardian Email
example@example.com
Father/Guardian Phone
-
Area Code
Phone Number
Tell us about your child:
How does your child ambulate?
Walk
Wheelchair
Crawl
Roll
Walker
What are your child's communication needs?
Predominately non-verbal
Somewhat verbal
Predominately verbal
Utilizes a communication device
Please explain how your child communicates. (Give examples of gestures or signs for certain words)
Please explain how your child best interacts with others.
Does your child read?
Yes
No
How are your child's fine motor skills? (select all that apply)
Able to write with assistance
Able to color with assistance
Able to write independently
Able to color without assistance
Is your child subject to seizures?
Yes
No
If your child is subject to seizures, a seizure protocol should be on file with Creekside Church before attending.
Does your child wander/run from teachers/classroom?
Yes
No
How does your child adapt to change? (Change in seating or schedule)
Does your child have any environmental sensory sensitivities? (sounds, lights, etc.)
Please list any allergies.
Please specify your child's toilet/hygiene needs:
Independent in the restroom
Help needed in restroom
What are your child's favorite motivators and/or calming activities?
What are some activities your child enjoys?
What activities does your child least enjoy?
Additional Information:
Submit
Should be Empty: