Children's Ministry Special Needs Intake Form

*Student's first and last name
*Student's date of birth
*Student's age
*Student's grade
Siblings names and ages (separate by comma, Indigo Jane 13, Thomas Lincoln 7)
School student attends

*Specific type of disability
*Diagnosis
*Does your child have seizures? What actions need to be taken?
*Does your child need assistance with eating, drinking or using the restroom/hygiene? If yes, what kind of help?
*Is your child verbal or non-verbal?
*Does your child use sign language?
*What does your child enjoy? What is especially troublesome for you child?

*If your child has had a previous experience at church, wast I positive or negative? Why?
*Does your child have phobias or fears? What are they?
*Does your child display any behaviors that might disrupt a class? If so, what do you or others do to help control those behaviors?
*What do you consider to be your child's greatest challenge in social settings?
What additional information should we know?


PARENT'S CONTACT INFORMATION
*Father's first & last name
*Father's email address
*Father's cell phone number
*Mother's first & last name
*Mother's email address
*Mother's cell phone number
*Address (Street, City, State & Zip)
Home phone number


GUARDIAN'S CONTACT INFORMATION
Guardian's first & last name
Guardian's email address
Guardian's Cell phone number
Guardian's address (Street, City, State & Zip)