Forever His Visitor Form

We Would LOVE for Your Family to Visit Us!

The Karns church of Christ welcomes children and adults of all ages, including those with disabilities, to attend Bible classes and worship services with us!

We want to provide a comfortable, safe environment that makes any modifications or accommodations necessary to provide a positive experience while you and your child are here.

In order to do this, we ask that you complete the form below so we will be better able to assist you and your child when you arrive.

If you have any questions, you can contact the Karns church at 865-691-7411 or email Kim Higginbotham at higginbotham.kim@gmail.com.
Child's Information
Child's Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Church:
Gender*

MaleFemale
Date of Birth (MM/DD/YY)*
Chronological Age*
Developmental Age*
Diagnosis*
Current educational setting or daytime activities*
Drug allergies (Type "none" if there are none.)*
Food or Other Allergies (Type "none" if there are none.)*
Nutrition/Dietary Information
Dietary Needs (Check all that apply)*

Can feed self without assistanceHas difficulty chewing or swallowingNeeds soft foodNeeds food cut into small piecesHas feeding tube (elaborate below)
Dietary: Any other special instructions
Toileting & Hygiene Information
Toilet & Hygiene*

IndependentNeeds supervisionWears diaper or Pull-upHygiene assistant (wiping, washing hands)Physical assist to transfer to toiletHas an ostomy (elaborate below)
Toilet & Hygiene: Any other special instructions
Mobility Information
Mobility*

IndependentPower chairWheelchairStrollerWalkerCrutchesService dogAdult hand-held assistance
Mobility: Any other special instructions
Health & Safety Information
Seizures*

Yes (elaborate below)No
Seizures: Special instructions and details*
If child does not have seizures, put "none" in this field
Other health issues*
List any medications your child is currently taking (If none, type "none")*
Attitudes and Behaviors*
How can we redirect inappropriate behaviors?*
How does your child react to people he/she does not know?*
What type of reward system is used with your child?*
Communication
Does your child use verbal or nonverbal communication?*

VerbalNonverbal
Does your child read?*

YesNo
Does your child write?*

YesNo
Does your child use sign language?*

YesNo
Is your child's speech understandable?*

YesNo
Can your child communicate his/her basic needs?*

YesNo
Any other information we need to effectively communicate with your child:*
Sensory & Physical Information
Does your child have any sensory processing issues? If so, please explain.*
Does your child have any physical limitations? If so, please explain.*
What type of physical apparatus/equipment does your child use, if any?*
Additional Information
"You didn't ask, but I want you to know this too..."*
Family & Emergency Contact Information
Parent/Guardian Name #1*
Relationship to Child*

FatherMotherGuardian
Home Phone*
Parent/Guardian Cell Phone*
E-mail
example@example.com
Parent/Guardian Name #2*
Relationship to Child*

FatherMotherGuardianOther
Parent/Guardian Cell Phone*
E-mail
example@example.com
How Did You Hear About the "Forever His" Ministry?
Briefly describe how you heard about us:
Should be Empty:

We Would LOVE for Your Family to Visit Us!

Child's Information