Form
We would love to have you join us!
Parents and caregivers, please fill out the form below so our team can create a customized care plan to meet your child's physical and spiritual needs. Our Disability Team will contact you to discuss the next steps for your child. Our staff and volunteers will respect your right to privacy with the information given on this form. The information shared will be directly with those caring for your family member on a “need to know” basis.
Child's Name
First Name
Last Name
Child's DOB
-
Month
-
Day
Year
Date
Child's Diagnosis
Does your child live at home?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Name
First Name
Last Name
Mother's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Mother's Email
example@example.com
Father's Name
First Name
Last Name
Father's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Siblings:
Name
Age
1
2
3
4
5
Enjoys music?
Yes
No
Enjoys Arts and Crafts?
Yes
No
Outside play?
Yes
No
Writing?
Yes
No
Reading?
Yes
No
Being read to?
Yes
No
Allergies/Food sensitivities
Are the allergies life-threatening?
Yes
No
EPI Pen?
Yes
No
Food or drinks to avoid
Assistance needed for eating/drinking?
Yes
No
Prone to seizures?
Yes
No
If yes please explain more:
Any other medical concerns:
Toileting needs:
Independent
With assistance
Wears diapers
Signs/gestures/words to indicate toileting needs:
Please list any medicines we should be aware of in case of emergency:
Main mode(s) of communication
Verbal
Visual supports
Sign language
Digital devices
My child is independent with:
My child needs assistance with:
My child is uncomfortable with or has sensitivities to:
Behavioral concerns to be aware of:
Trigger points for frustration/resistance:
Calming tools/aides:
Behaviors that may communicate a specific need (please indicate the need where appropriate):
Classroom situations you wish to be contacted about:
Please describe your child's understanding of and relationship with God:
Ideas for church to better serve your family:
Additional thoughts or comments
Submit
Should be Empty: