Caring for FCC Kids with Exceptionalities
These questions allow us to provide the best experience and safest environment for all of our friends within the ministry. Our church leaders and ministry volunteers will respect your family’s right to privacy. Any information shared is communicated directly with those caring for your family member and only on a “need to know” basis. If you have any questions, please contact Pastor Holly for more information.
Child's Name:
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Does your child have a diagnosis?
*
Parent #1 Name
*
First Name
Last Name
Parent #1 Phone Number
*
Please enter a valid phone number.
Parent #1 Email
example@example.com
Parent #2 Name
First Name
Last Name
Parent #2 Phone Number
Please enter a valid phone number.
Parent #2 Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List Siblings and ages
My Child loves to:
My Child enjoys
arts and crafts
music
outside play
writing
reading
Other
list Allergies/Food sensitivities:
Any list any life threatening allergies:
Does your child carry an epi pen? We do have an onsite epi pen for emergencies.
yes
no
Assistance needed for eating/drinking?
yes
no
Prone to Seizures?
yes
no
Toileting needs:
*
independent
with assistance
wears diapers
Other
Signs, genstures, words to indicate toileting needs:
Main form of communication:
*
Verbal
Visual supports
sign language
digital devices
Other
Trigger-points for frustration/resistance:
My child is independant with:
My child needs assistance with:
My child is uncomfortable with or has sensitivities to:
Behavior concerns to be aware of:
Calming tools and aids:
Behaviors that may communicate a specific need (please indicate the need where appropriate)
Classroom situations you wish to be contacted about:
Please describe your child’s understanding of and relationship with God:
Goals for your child at church:
*
Ideas for the church to better serve your family:
*
Additional thoughts or comments:
Submit
Should be Empty: