Ranger's Questionnaire

Rangers Questionnaire

This form is designed to help us best serve your child's unique needs during their time with us in Compass Kids. Note that this form is for children who need a little extra help while they're with us. We will review this information and contact you promptly. Since it is our aim to provide the highest level of care, we may not be able to accommodate every situation due to space or team limitations. Thank you for taking the time to help us make your child feel right at home! In addition to the information provided on this form, if you would like to send us your child's IEP/Services Plan if applicable, feel free to do so!
Student Name*

First NameMiddle NameLast Name
Parent Name

First NameLast Name
What Service Are You Planning to Attend?
Birth Date

MonthDayYear
Gender*
Parent's E-mail*
example@example.com
Parent's Mobile Number*
Format: (000) 000-0000.
Please list any sensitivities we should be aware of.*
Does your child require assistance using the bathroom?*

YesNo
If your child becomes upset, what are some things they would find comforting? (going for a walk, a comfort item, etc.)*
In your opinion, would your child do best in an environment that is age based or developmentally based?*

DevelopmentallyAge
What is your child’s primary method of communication?*

SpeakingGesturesPECS boardNon-verbalOther/AAC
Has your child been diagnosed with a special need? If so, please describe.*
Would your child enjoy a large group worship experience? If not what is the reason? (Too loud, too much movement, too dark)*
What activities does your child need assistance with?*
I would like to be notified when my child exhibits the following behavior:*
Is there anything else we should know about your child?
Please explain any medical conditions (other than allergies) that we should know about.*
Does your child require a medical device of any kind? If so, please describe.*
Does your child have any behaviors or signs that let us know medical attention will be needed?*
At what point should we contact you or a medical professional?*
List Allergies. Please note if allergies are ingested, contact, or inhaled allergies.*
Are any of these allergies life threatening?*

YesNo
How did you hear about our Ranger's program?

Friend/Family MemberWebsiteTeam MemberOther
Should be Empty:

Rangers Questionnaire