Joy Ministry Participant Form

JOY Ministry Participant Information

The following questions allow us to provide the best experience and safest environment for all of our friends within the ministry. Our 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 you have any questions, please contact Jenny Woodard at jenny.woodard@uhbc.net. We look forward to serving your child and family.
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Biological Age*
Developmental Age*
Grade in School*

SPECIFIC TYPE OF DISABILITY OR NEED*
DIAGNOSES*
SEIZURES?*

YesNo
PLEASE LIST TYPES, AVERAGE LENGTH, FREQUENCY, AND TRIGGERS*
SHOULD WE EXPECT TO SEE ANY WHILE IN OUR CARE?*

YesNo
HOW CAN WE BEST ASSIST YOUR CHILD IN THE CASE OF A SEIZURE UNTIL A PARENT/GUARDIAN ARRIVES?*
ALLERGIES?*

YesNo
PLEASE EXPLAIN*
WHAT SNACKS DOES YOUR CHILD PREFER?*
WHAT OTHER MEDICAL/PHYSICAL ISSUES ARE THERE OF WHICH WE NEED TO BE AWARE?

I certify that University Heights Baptist Church has permission to care for the child listed on this form and participate in planned activities of Joy Ministry. I certify that I have disclosed all information about my child's needs, and I will not hold University Heights Baptist Church or an individual volunteering in their program liable for any injury that may occur while my child is in their care. I understand that the caregivers are volunteers who will not administer any medication to my child and who are not equipped to provide emergency medical care. I have provided the caregivers with a valid phone number at which they can reach me if they have questions or concerns while my child is in their care.

**I will remain on the premises of University Heights Baptist Church while my child is in the Joy Ministry's care so that I can be easily accessible in the event of an emergency.
Signature
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JOY Ministry Participant Information