Together at Warren New Student Registration

Student Registration Form
The following questions are asked for the benefit of your student, and so that we may provide the best experience and safest environment for everyone involved. Our church leaders and ministry volunteers respect your family's right to privacy. Any information shared from this form is communicated directly with those caring for your child and only on a "need to know" basis. You will be contacted by a Together at Warren staff member within 24 hours, Monday – Thursday, after submitting this form.

You must meet with and/or speak to a Together at Warren staff member prior to your first visit so we can be fully prepared to care for your student.
Basic Student Information
Name

First NameLast Name
Gender:

FemaleMale
Date of Birth

MonthDayYear
Date
What school/center does he/she attend (if applicable)?
Parent/Caregiver Information
Name

First NameLast Name
Relationship to the student
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
May we contact you through text message?

YesNo
Check the times and days you are interested in having your student attend Warren.

Sunday Morning 9:15Sunday Morning 10:45Wednesday Evenings 6:15 (available during the school year)
Where will you be while your child is attending Together at Warren? (The parent/caregiver must be on the Warren campus while the student attends Together at Warren for students high school and younger.)

Worship CenterLife GroupWednesday Night Group
If attending Life Group or a Wednesday Night Group, please give the Group Leader name and the room number.
Student Specific Information
Where would you prefer your student be placed?

Inclusion with a buddySelf-contained room
Is your student verbal or non-verbal?

Non-verbalVerbal
What is the best way to communicate with your student? (One step directions, sign language, picture cards, etc.)
What devices, equipment, and/or other items does your student successfully use at home or school?
What is the chronological age of your student?
What is the developmental age of your student?
What are some things your child loves to do or has a special interest in?
Is your student physically harmful to himself/herself or others?

YesNo
If yes, please explain.
Please list any medical needs or allergies that we should be made aware of.
Please check which of the following snacks that your student may have:

animal crackersgoldfishpretzels
Additional notes about Snack and Food.
More About Your Student
Please share your student's diagnosis or disability.
Does your student elope (escape/run away)?

YesNo
What are your main concerns for your child at this event?
Please explain any sensory or behavioral needs your student has.
Does your student need assistance in the restroom? If so, explain.
Additional Information
Is there any other information you would like for our team to know?
I consent to allowing my child to be photographed and understand these images may be shared on the Warren website and/or social media:*

YesNo
Medical Consent
Name
Diagnosis/Disability
Student's Primary Physician
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Phone Number
Please enter a valid phone number.
Hospital Preference
Current Medication
In case minor first aid is needed: (Example: a cut needs a bandaid)

Administer first aid and then callCall before administering any type of first aid
LIABILITY RELEASEPLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND CHECK THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS.

I have fully disclosed to Warren Baptist Church all pertinent facts about my child’s special needs (Cognitive, Physical, Mental, Medical) and accept full responsibility for missing information. I agree for this information to be disclosed to the approved volunteers at Warren as appropriate, so they may best care for my child. I acknowledge and accept the risks of injury associated with my child’s pre-existing condition while participating in Ministry activities. I acknowledge and accept the risks of injury or harm associated with intervention and/or treatment performed by Ministry workers. I agree on behalf of both the guardian and the child, to indemnify, defend, and hold harmless the ministry, and its agents, employees, volunteers, and other representatives for any injury or incident arising directly or indirectly out of the described medical needs of my child.
I have read, understand, and agree to the provisions listed above.

YesNo
Parent/Caregiver Name
Relationship to student
Phone Number
Please enter a valid phone number.
Does your student have a history of seizures?

YesNo
If your student has a history of seizures, please fill out the following Seizure Action Plan:
Seizure Action Plan: Contact Parent/Caregiver if:
Seizure Action Plan: Call 911 if:
Consent: By selecting yes in the following area, you are acknowledging that all information regarding the Seizure Action Plan is true to the best of your knowledge. Also, by filling out the information in the Seizure Action Plan, you are giving permission to the representatives of Warren Baptist Together at Warren Special Needs Ministry to act as you have indicated on behalf of your student.

YesNo
Parent/Caregiver Name
Relationship to student
Phone Number
Please enter a valid phone number.
Emergency Contacts (other than person whose information has already been provided)
Name
Phone Number
Please enter a valid phone number.
Name
Phone Number
Please enter a valid phone number.
Should be Empty: