Vintage Buddies Information Form
These questions allow us to provide the best experience and safest environment for all of our friends within our buddies 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 Katie Harrison at katieh@vintagegrace.org for more information.
Child's Name
*
First Name
Last Name
DOB
*
Diagnosis
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Mothers Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Living with child
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
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Fathers Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Living with child
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Siblings name and age
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Allergies or Food Sensitivity
*
Yes
No
If yes, please explain
Epi Pen
*
Yes
No
Assistance needed for eating or drinking?
*
Yes
No
Prone to seizures?
*
Yes
No
Medical conditions we should be aware of?
Toileting needs
*
Independent
Needs assistance
Wears diapers
Main modes of communication
*
Verbal
Visual supports
With assistance
Digital devices
My child interests are
*
My child's dislikes are
*
Behavior concerns to be aware of
*
Trigger points for frustration/resistance
*
Calming tools and aids
*
My child struggles with
*
Does your child have a preference for a male or female buddy?
*
Male
Female
No preference
Goals for your child at church
*
How can we best support your family?
*
What would you like us to know about your child?
When are you planning to attend Vintage for the first time?
Submit
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