Special Needs Ministry Questionnaire
RCC cares for each participant in family ministry programming. These questions are asked for the benefit of your child so that we may provide the best experience and safest environment for everyone involved. Our church and family ministry workers respect your family’s right to privacy. Any information shared from this form is communicated directly with those caring for your child and only on a “need to know” basis.
Attendee's Name
*
First Name
Last Name
D.O.B.
*
/
Month
/
Day
Year
Age
*
Sex
*
Male
Female
Guardian's Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to Attendee
Mother
Father
Grandma
Grandpa
Cousin
Aunt
Uncle
Brother
Sister
Guardian's Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to Attendee
Mother
Father
Grandma
Grandpa
Cousin
Aunt
Uncle
Brother
Sister
Contact
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to Attendee
Mother
Father
Grandma
Grandpa
Cousin
Aunt
Uncle
Brother
Sister
Add New Contact?
Yes
No
Attendee has the following diagnosis, medical conditions, or learning differences:
Please check any that are applicable to your child that teachers/leaders will find helpful as they minister to your child:
easily distracted
aggressive behavior
speech/communication difficulties
fine motor skills (cutting/pasting)
gross motor skills (walking/jumping)
trouble with sensory experiences
runs/leaves area without permission
aversion to water, lights, loud sounds, etc.
hearing/vision challenges
difficulty in social settings
tantrums/melt-downs
seizures
changes in routine
transitions
following directions
allergies
Other
Comments:
Please list allergies:
Are there any accommodations for your child that may better help them better participate in church programs?
fidgets
pressure vest
mini trampoline
weighted blanket
hard putties
objects with blinking lights
calm/quiet music
a darkened environment
noise cancelling headphones
visual directions/schedule
special bathroom needs
Other
Comments
Please list any special bathroom needs or directions:
Are there steps you want us to follow in case of a medical emergency? If so, please list.
Submit
Print Form
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