Intake Form - Disability Ministry

This form is intended to help us learn how we can best help your child be fully included in our kids or student ministry. Please be as extensive as possible and fill out one form per child with a disability. Thank you!

Your name *

Email address *

Phone number *

Address *

FAMILY INFORMATION

Child's Name *

Child's Birthdate (mm/dd/yyyy) *

Parent/Guardian Name *

Parent/Guardian Phone Number *

Parent/Guardian Name

Parent/Guardian Phone Number

Siblings

HEALTH/PERSONAL CARE INFORMATION

Diagnosis *

What is your child's diagnosed disability?

Medications *

Does your child take any prescribed medications? Or any over the counter medications regularly?

Allergies *

Is your child allergic to any medications? Are there non-medication allergies that we should be aware of?

Seizures *

Is your child a seizure risk?

Does your child have toileting needs? *

ACCOMMODATIONS

Sensory Preferences

Select any that your child likes.

Deep pressure/hugs

Light touch

Other

Sensory Aversions

Select any that your child does not like.

Loud noises

Certain textures

Other

Does your child use alternative communication strategies? *

Does your child require any fine or gross motor accomodations? *

BEHAVIOR/SAFETY INFORMATION

Does your child have a behavior plan? *

If yes, a copy would be helpful for us.

LIKES/PREFERENCES

What are three objects or toys your child loves? *

What are three activities your child loves? *

Photo Consent

I voluntarily authorize First Baptist Hanford to take, display, and/or publish pictures of my child participating in classroom activities. I understand that pictures would be used solely for the purpose of advertising and promoting special needs ministry or general ministry, with no personal information disclosed.

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