Persons with Disabilities Information Form 2024-2025

St. Raphael REACH Program

Persons with Disabilities Information Form 2024-2025 To be filled out by Parent or Guardian
Child's Name*

First NameLast Name
Home Address*

Street Address

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Parent or Guardian Name(s)*

First NameLast Name
Parent or Guardian Phone Number*
Please enter a valid phone number.
Parent or Guardian Email(s)*
example@example.com
Parish*
Type of disability, if known:*
Brothers/sisters name & ages and include names and types of pets
Interests and Hobbies:*
General Education & Religious Education Background
School attended and include School District*
Type of Educational Program (i.e. mainstreamed, special education classroom, etc.)*
What sacrament(s) has your child received? Check all that apply

BaptismEucharistReconciliationConfirmation
1. Number of years of Religious Education 2. Is your child attending another religious education program? If so, what is the church/program*
Current Interest In/Exposure to Religious Experiences (select all that apply)*

Church AttendancePrayer at homeReligious instruction from parents, godparents, others
Medical and Physical Considerations
Medication (Be specific) Include Special Considerations*
Gross Motor Skills*

PoorFairGood
Fine Motor Skills*

PoorFairGood
Communication Considerations
Language Skills- Check all that apply*

No difficulty in giving verbal responsesSpeech is difficult to understandAsk for child to repeat backYes or no responsesProcesses slowlySign LanguagePECS
Other considerations:
Written Communication

Select Yes or No
No difficulty writing*

YesNo
Can your child read*

YesNo
If yes, at what grade level?
Communication Visually- Check all that apply*

Material in large printBrailleMaterials on tapeNeeds someone to read with themCannot write or print, but uses typewriter/computerNeeds some assistance in writing (demonstrate)Child can tape record responsesChild needs someone to write down responses
Other Considerations:
Communication Hearing- Check all that apply

Child is hard of hearingChild is deafKnows ASL (American Sign Language)
Other Considerations:
Learning Style- Check all that apply*

Learns from what he/she hearsLearns from what he/she seesLearns from what he/she is involved in doingLearns from what he/she touches or handlesLearns from what he/she talks about
Other Considerations:
Attention Span

Fill out the question below.
What helps hold the child's attention?*
Distractibility

Fill out the question below.
What types of things are distracting to the child? (visual stimuli, sounds etc.)*
Behavior

Fill out the questions below and include any considerations.
Signs of unhappiness, agitation or emotionally upset are:*
Events that might trigger these behaviors and ways to help regain emotional equilibrium*
Mobility- Check all that apply*

No need for assistanceUnsteady/needs a friend at his/her sideWheelchair with no assistanceWheelchair with some assistanceWalkerCrutchesCane
Other considerations: (explain)
Visually & Hearing Impaired

Special Considerations
List any other devices used to aid child
List any other devices used to aid child (hearing aids, BAHA, cochlear implant, FM system)
Bathroom Skills- Check all that apply*

IndepedentNeeds some assistanceTotal assistanceCatheter
Other considerations: (explain)
Allergies:
Please list any food or environmental allergies*
Important Information

Please fill out each subcategory
Other relevant medical needs or information:*
Please give us any information about your child's capabilities, strengths and fears to help us give your child an awareness of God's love in their life and to help him/her find their own special gifts:*
Does your child need a R.E.A.C.H T-shirt? If so, what is your child's T-Shirt size (they do shrink). Youth XS, S, M,L, XL or Adults S, M, L, XL, XXL, XXXL, XXXXL*
I give permission for REACH photos*

YesNo
Would you like to be a volunteer at REACH?*

YesNo
Should be Empty:

St. Raphael REACH Program

General Education & Religious Education Background

Medical and Physical Considerations

Communication Considerations

Written Communication

Attention Span

Distractibility

Behavior

Visually & Hearing Impaired

Allergies:

Important Information