New Student Registration Form

New Student Registration Form

Our Saturday School offers a specialized education program tailored for friends with disabilities, ensuring an inclusive and enriching learning environment.
Student Name*

First NameLast Name
Gender*

MaleFemale
Disability*

AutismCerebral Palsy (CP)Intellectual Disability (ID)Other
Phone Number
(000)000-0000
Birth Date*

MonthDayYear
MM-DD-YYYY
Name of School
Special Education Training Program

SpeechMusicPhysicalOccupationalAdapted P.EArtOther
Baptismal Status

Not baptizedBaptized as an infantBaptized as a childBaptized as an adultPlanning to be baptized
Support Student Needs

Financial SupportEmploymentMedical CareGroup HomeVacation TrainingInformation of BenefitsOther
Emergency Contact Information

In case of an emergency, please provide the names of people who are authorized to pick up your child from Watered Garden Disability Mission. Only those listed will be allowed to pick up your child; anyone not mentioned will need a written permission slip from a parent to do so.
Emergency Contacts*
Student's Living Situation
Family Member(s)

FatherMotherSiblingsSisterOther
Living Arrangement

With familyWith roomate(s)Live independentlyGroup homeOther
Parent/ Guardian Contact Information
Parent/ Guardian Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Address*

Street Address/ City/ Zipcode

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Primary Care Physician's Info.
Physician Name*

First NameLast Name
Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Medical History
Student have allergy?*

No, do not have allergyYes, do have allergy (Please describe)
Student have constipation?*

NoYes
When was the student's most recent primary care visit?
What kind of treatment did the student receive recently?

학생이 현재 복용 중인 약물은 무엇입니까?

	Medication	Strength	Dosage	Time Schedule	Reason for Medication
1
2
3

Self-Management Skills

Vision

	예	아니요
Is student visually impaired?
Does the student wear glasses?

Mobility

	예	아니요
Can the student move around independently?

어떤 도구를 사용하고 있습니까

WheelchairRollatorCrutchesLeg bracesOther
How can we assist you in getting around?

Eating Habits

	예	아니요
Can you feed yourself?
Do you drink from a cup?
Do you eat with your hands?
Do you sometimes eat too much?
Do you sometimes eat too much?
Do you have a specifically prescribed diet?
Do you have any food allergies?

If there is a specifically prescribed diet, please provide detailed information.
If there are any food allergies, please provide detailed information.

Toileting

	예	아니요
Can the student go to the restroom by themselves?

If the student cannot go to the restroom by him/herself, how does he/she express it?
Please send underwear, diapers, and spare clothes if the student cannot properly handle bowel movements.

Communication

	Yes	No
Uses hearing aids?
Does the student respond to his/ her name?
Are you mumbling words that are not well understood?

How does the student express themselves?

Speaks signGesturesRead lipsUses communication boardOther
The most effective communication method that can be used for the student to understand well is?

Behavioral Characteristics

	Please describe in detail the student's way of expressing emotions.
Anger
Fear
Anxiety
Socializing with new people
Around large group of people
Avoidant situation
Self-harming situation

Favorite things/ activities
Pet peeves/ activities
Triggers/Behaviors to be aware of
Do you have any advice on managing student behavior?
Parent/Guardian Release of Liability Agreement
I (parent/ guardian's name),blanks* hereby permit the student (student's name) blank* to participate in activities conducted by Watered Garden Mission and agree to the following:
1. The student's participation in activities at Watered Garden Mission is voluntary. Watered Garden Mission does not require participation but merely encourages it. The student's participation in activities at Watered Garden Mission is under the responsibility of the parent/guardian.
2. Therefore, I waive any claims against Watered Garden Mission, its representatives, agents, volunteers, and employees for any personal injury and/or property damage that may occur to the student as a result of participation in activities at Watered Garden Mission.
3. In case of emergency, I authorize and permit Watered Garden Mission to consent to any necessary medical diagnosis, treatment, and hospital care for the student under general or special supervision and upon the advice of a licensed physician and surgeon.
4. I waive rights under Section 1542 of the California Civil Code, which states: "A general release does not extend to claims that the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her must have materially affected his or her settlement with the debtor."
5. I confirm that, except for promises, inducements, or agreements made to me, there have been no other promises, inducements, or agreements, and I agree to allow the student to participate in activities at Watered Garden Mission.
6. Watered Garden Mission is not responsible for the storage or safety of the student's personal belongings.
7. I approve the student's attendance and participation in activities at Watered Garden Mission.
8. I consent to Watered Garden Mission's employees or volunteers using any photographs, audio, or visual recordings related to the student without limitation or compensation. Please indicate below if you do not agree.
Parents/ Guardian Signature*

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Today's Date*

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Thank you for your interest in Saturday School. Our team will be reaching out to you shortly to assist with onboarding your student.
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New Student Registration Form

Emergency Contact Information

Student's Living Situation

Parent/ Guardian Contact Information

Primary Care Physician's Info.

Student's Medical History

Self-Management Skills

Parent/Guardian Release of Liability Agreement