Wonderfully Made Intake Info
Please fill out the form to help us understand the needs of your child here at Fayette Baptist.
Parent/Guardian's Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Any nicknames?
Current School
Grade Level
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Any allergies or health concerns (seizures, etc.)
Does your child have a specific diagnosis or receive any kind of therapeutic services? (school, home, clinic)
How does your child communicate wants/ needs? (anything other than verbal language such as use of an AAC device)
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Tell us a little about your child's favorite things to do, likes/dislikes, what they are good at? (Also, include any specific sensory toys, characters, games that your child enjoys)
Does your child need any assistance with any basic skills- feeding, toileting, mobility? If so, please describe.
What calms or comforts your child? Also let us know anything specific that could cause them to feel unsafe or unsettled.
What are triggers for dysregulation or signs of frustration that they may show? (Vocalizations, eloping, specific phrases, physical movements) Please also include any concerns of behaviors that could be harmful to others around him/ her.
How is your child with separation from you? Do they have any kind of issues with transitions?
Describe your child's understanding of Jesus and his/her current relationship with Him. (This will help us to know more about how we can tailor our curriculum and lesson plans.)
Is there any additional information that you would like us to know?
We may sometimes publicize aspects of our ministry to reach other families and volunteers. The use of your child's name and photo being used is strictly voluntary. Please indicate below if you consent for your child's photograph to possibly be used for positive outreach for the Wonderfully Made Ministry.
Yes
No
Parent/ Guardian signature
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