Child's Name
*
First Name
Last Name
Birthday
*
MM
DD
YYYY
Grade in School
*
Developmental Age
*
Child lives with:
To help us understand the uniqueness of our friend, please explain the nature of their disability (include the name of the syndrome, if known).
Degree of severity of the disability
What special equipment does your child use, if any?
Does your child take medication?
*
Yes
No
If yes, what medications?
Please list any known allergies to food, medication, environmental, animal, etc
Child's fine motor skill disability level:
*
Child's gross motor skill disability level:
*
What are the primary ways that your child communicates with others?
How does your child indicate "yes" or "no" when asked if he/she wants something, wants to go somewhere, or wants a person?
Will child use other behavior(s) to communicate a want/need?
Toilet/Hygiene Skills:
*
Please share any signs or gestures that your child may give to indicate his/her need to be changed or go to the bathroom.
Please share with us about any behaviors of which we should be aware.
When do these behaviors typically occur?
Are they more likely to occur with a specific gender?
Yes
No
If yes, which gender?
Female
Male
Please explain the behavior management plan that is being used at home and school to modify inappropriate behavior that may be exhibited.
*
What is your child's response to separation?
What is your child's response to playing with other kids?
List activities, toys, or games that your child enjoys.
What are some positive activities, games, statements, or actions that are helpful to reinforce positive behavior?
*
Other important information:
Parent/Caregiver Name
*
First Name
Last Name
Phone
Parent/Caregiver's phone number
(###)
###
####
Prefered Contact Method
Phone Call
Text
Email
Authorization Date
*
MM
DD
YYYY
Declaration of Consent
I agree to release Pioneer Church staff and volunteers from all liability for any additional illness or injury to my child and for any accidental damage or destruction of my child’s property while they are in the care of the children’s ministries at Pioneer Church. The signature and date below verify that I have read the above authorization statement and agree to the terms designed in each.
Consent Date
MM
DD
YYYY
