Exceptional Grace Ministry
These questions allow us to provide the safe and best experience for all of our friends within the 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 Melissa Kiser at melissa@graceweb.tv for more information.
Name of Person with Special needs
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Diagnosis
Name of Mother/Guardian/Caregiver
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Name of Father/Guardian/Caregiver
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Siblings? If yes, please list names and ages.
Living Arrangements
Medical Supports
Allergies/Food Sensitivities
*
Yes
No
If yes, please explain:
EPI Pen
Yes
No
Life Threating?
Yes
No
Food/drinks to avoid:
Foods/drinks he/she enjoys:
Need any assistance for eating/drinking?
Yes
No
If yes, how can we assist?
Prone to Seizures
Yes
No
If yes, what is the seizure plan to follow?
Toileting Needs:
Independent
With Assistance
Wears Diapers
Is there any signs, gestures or words that he/she typically does to indicate needing bathroom?
Please include any support needed with toileting.
Medication
Yes
No
Does medication needed to be given at church?
Other Medical Needs we should be aware of to support:
Interests
Enjoys Music
Yes
No
Enjoys Arts & Crafts
Yes
No
Gross Motor Play
Yes
No
Reading
Yes
No
Writing
Yes
No
What else does he/she enjoy to do?:
*
What activities does he/she not like?
*
Communication and Behavior Supports
Main mode(s) of communication:
Verbal
Visual Support
Sign Language
Digital Devices
Behaviors that may communicate a specific need (please indicate the need where apporopriate):
Is there anything that makes him/her uncomfortable with or has sensitivities to?:
*
Behavior concerns to be aware of:
What works best to deescalate situation? Any Calming tools or visual aids?:
*
Trigger-points for frustration/resistance:
*
Is there any situations that you wish to be contacted about:
*
Spiritual Walk
Can you describe his/her understanding and relationship with God:
Has he/she been baptized before?
Goals for your child at church:
*
Ideas for the church to better serve your family:
Do you give Grace Church consent to take pictures and videos for church website and church social media pages?
*
Additional thoughts or comments:
Submit
Should be Empty: