Pure KIDZU Child Information Form

Pure KIDZU Child Information Form

It is our goal at the Vine to welcome children of all abilities to become a part of KIDZU, to pour into them the love of our Heavenly Father and to enable them to become active disciples for Christ. With that in mind, please take a moment to consider the questions below and provide us with all information that will allow us to serve your child safely and with maximal impact for their learning needs.
Parent & child info
Which campus do you usually attend?
Parent's name(s)

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child's name

First NameMiddle NameLast Name
General information
Health concerns, diagnosis, medical condition, or learning difference:
We love getting to know your child! Please share their interests:
Please share any behavioral concerns we need to be aware of (even if it is a rare occurrence). Please include all occurrences of aggressive or self-injurious behaviors that have happened past/present. This is super helpful to know so that we can prepare for the most successful and safest experience possible. We have trained sped teachers and volunteers that work very well with behavioral needs.
Are there any known triggers that produce challenging behavior?
Please describe what behaviors look like when your child is frustrated: (ex: crying, hitting, kicking, running away, etc.)
When my child experiences a period of frustration, he/she calms when we:
What reinforcers do you currently use? (Ex. Food, stickers, music, specific toys, time on iPad, etc.)
Is there anything that your child is very particular about that might impact their time in Kidzu?
What signs or behavior may indicate a medical problem requiring immediate attention?
We know every person has special traits that make them unique and amazing! Please share some of your favorite things about your child with us:
Preferred setting
Allergies
List all allergies
Does the child carry emergency medication for allergy exposure?
If yes, provide details of the emergency medication, when it should be used and where it will be located:
What specific treatment is required if exposure occurs based on symptoms seen?
Communication needs
Communication methods used

Other
What the child understands when spoken to

Other
Vision needs
Vision status
Compensatory strategies or assistive devices used to navigate the environment:
Self-care needs
Restroom hygiene

Other
Special instructions for restroom:
Eating habits

Other
Special instructions or other self-care needs:
Sensory integration needs
How does the child process instructions or information best?
Sensory input the child seeks:
Sensory aversions or uncomfortable stimuli:
How the child shows over-stimulation:
What comforts or calms the child?
What need the child is communicating when this behavior occurs:
Additional sensory diet details that may help at KIDZU:
Seizure plan of action
Has the child had seizures in the past or is the child prone to seizures?
Seizure type and typical duration:
Seizure triggers, warning signs, and symptoms:
VNS device and instructions, if applicable:
Emergency seizure medication details:
When should emergency seizure medication be administered?
Emergency contact #1 name
Emergency contact #1 relation to child
Emergency contact #1 phone number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact #2 name
Emergency contact #2 relation to child
Emergency contact #2 phone number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact #3 name
Emergency contact #3 relation to child
Emergency contact #3 phone number
Please enter a valid phone number.Format: (000) 000-0000.
Who should be called first in case of a seizure?
Who should be called second in case of a seizure?
Who should be called third in case of a seizure?
When should the team call 911 during a seizure event?
Any other seizure-related information helpful for the team?
Should be Empty:

Pure KIDZU Child Information Form

Parent & child info

General information

Allergies

Communication needs

Vision needs

Self-care needs

Sensory integration needs

Seizure plan of action