Intake Form

Individual Worship Plan

These questions allow us to provide the best experience and safest environment for all of our friends within the ministry. New Covenant 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 your child has a school IEP it might be beneficial to share a copy with the ministry leader. If you have questions, please contact Amy Lesko or Abby Briggs for more information.
Child's Full Name

First NameLast Name
What is his/her age?
What is his/her birthdate

MonthDayYear
Date
What is his/her gender?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Diagnosis:
School IEP available
Main Caregiver

Full NameRelationship to Child
Contact Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Caregiver

Full nameRelationship to Child
Contact Number
Email Address
example@example.com
Sibling(s)'s Names & Ages
Allergies/Food Sensitivities? If yes, please explain.

YesNoLife Threatening?EPI Pen?
Please list them.
Foods/drinks to avoid:
Assistance Needed for eating/drinking?

YesNo
Prone to Seizures? If yes, please see additional questions.

YesNo
Prior to having a seizure, the following behavioral changes may occur:
During a seizure, the participant will exhibit the following behaviors:
After the seizure, the participant will exhibit the following behaviors:
Other Medical Concerns:
Medication:
Type & purpose
Toileting Needs: *NOTE: Volunteers for kids will walk the child to the restroom door, but not accompany them into the restroom. Volunteers will not assist with personal restroom care, changing diapers or briefs. Parents or care providers will be contacted if this is needed.
Signs gestures, words to indicate toileting needs?
Please check any tasks where support will be needed:

Staying on taskWritingCommunicating with othersStaying in classroom/buildingReading aloudInteraction with othersUnderstanding DirectionsRespecting personal spaceManaging loud noisesEatingOther
Main mode(s) of communication

VerbalVisual SupportsSign LanguageDigital Devices
My child is independent with blanks .
My child needs assistance with blank .
My child is uncomfortable with or has sensitivities to blanks .
Medical/behavior concerns to be aware are:blanks.blank
Trigger points for frustration/resistance are:blanks.blank
Calming tools and aids that he/she uses are:blanks .
Behaviors that may communicate a specific need (please indicate the need where appropriate):blanks
Classroom situations you wish to be contacted about:blanks
My child loves to:blanks
Check all the things that your child enjoys:

MusicArts & craftsOutside PlayWritingReadingOther
The following questions are optional.
Please describe your child's understanding of and relationship with God.
Goals for your child at church:
Ideas for church to better serve your family:
Additional thoughts or comments
Should be Empty:

Individual Worship Plan