Children’s Ministry Special Consideration Form
Share any needs or details we should know to support your child in the program.
Child's Full Name
*
First Name
Last Name
Child's Age
*
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
My child has a 504/IEP Plan
Yes
No
My child is really good at:
My child is interested in:
My child responds to separation from his/her parents by:
Please provide us with background information that you would like us to know:
My child has special consideration in the following area(s)
Medical
Behavioral
Communication
Sensory
Developmental
Physical
My child currently receives therapies and/or special instruction in:
Which type of classroom does your child participate in?
*
General education
Homeschool setting
Self-contained/separate classroom
NA or other
My child is picky/inflexible or has an aversion to
A trigger-point for a potential meltdown is when:
What helps my child to calm-down or regulate when they are upset:
My child seems most relaxed in this setting*
*
Alone
With a few children
Among many children
Hearing*
*
Typical
Mild/moderately impaired
Severely impaired
Vision*
*
Typical
Mild/moderately impaired
Severely impaired
Toileting*
Toilets Independently
Potty trained; needs assistance
Wears diapers
Potty training – in process
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Second Emergency Contact Name
First Name
Last Name
Second Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: