Special Needs Family Iftar
MUHSEN CHICAGO - Mecca Center, Saturday Feb 28th. Respite care provided after Iftar during Taraweeh Salah in the banquet hall.
Caregiver Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Number of Children Attending:
*
Number of Adults Attending:
*
Would you like respite services during Taraweeh Salah for your participant with special needs?
*
Yes
No
Back
Next
Gender of participant
*
Female
Male
Name of Participant
*
First Name
Last Name
Disability of Participant:
*
Age of Participant
*
Do they have some kind of supportive device? If so, what is it?
*
What is their best mode of communication?
*
What do they find challenging?
*
What are the challenging behaviors we are likely to see when they are upset?
*
How should one calm a negative behavior?
*
List any dietary restrictions for them? Do they have any allergies? Any food sensitivities/texture sensitivities
*
List any applicable information for toileting
*
What are their preferred activities?
*
What are some strengths of theirs that we can build on?
*
Is there any additional information you would like to share?
*
Submit
Should be Empty: