Special Needs Classroom
Child Info Sheet
*For returning guests, only provide child's name to let us know you'll be here.*
Thank you!
Name
*
First Name
Middle Name
Last Name
Which service will you be attending?
*
First service 9:15
Second service 10:45
Birth Date
-
Month
-
Day
Year
Date
Where is child's primary residence?
with both parents
with mother
with father
with guardian
Primary Medical Diagnosis/Condition (if not applicable write "none"):
List any Secondary Diagnoses/Conditions:
Parent/Guardian Information
Name
First Name
Last Name
Relationship to child:
Primary Telephone:
-
Area Code
Phone Number
Secondary Telephone:
-
Area Code
Phone Number
Email:
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Care & Activity Information
Does your child like to be called by any other name?
Age:
Current grade in school:
Height:
Type a question
Type a question
Type a question
This is a fill in the
blanks
field. Please add appropriate
blank
fields and text.
Weight:
Gender:
Male
Female
Please choose the appropriate information below:
Ambulation; wheelchair
manual
electric
Ambulation; other
walker
crutches
braces
walks alone - no devices
Wanders?
yes
no
occasionally
Behavior
no problems
use time out
If you use time out for behavior, how many minutes?
Problems are triggered by:
Positive reinforcers?
Suggestions?
Toilet management
no problems
diapers
training pants
catheterization
self catheterization
Needs help with:
Eating:
no assistance needed
regular diet
tube feedings
G-tube
NG-tube
Food must be:
cut
chopped
mashed
pureed
Needs help with:
Special diet:
Seizures:
none
has seizures
Date of last seizure (if applicable):
-
Month
-
Day
Year
Date
Type:
Usual duration:
Usual frequency:
Triggered by:
Communication:
no problems
non-verbal
sign language
limited abilities
can communicate personal care needs
communication device
If communication device is used - what type?
Hearing:
no problems
oral deaf
hearing impaired
wears aides
Vision:
normal
wears glasses
limited
blind
Heat tolerance
good
fair
poor
Any allergies (food, environmental, etc.) we should be aware of?
Is your child latex sensitive?
Yes
No
Anything else you would like us to know specifically about your child?
Submit
Should be Empty: