Phone number *
Phone type Mobile Home Work Other
Child's Classroom Setting at School
Check all that apply
Allergies
Please specify all allergies, such as food, environmental, etc.
Medical Concerns
Although we do not provide medical care or administer any medication, please tell us anything that would be helpful for our volunteers to be aware of: g-tube, seizures, ostomy bag, etc.
Communication *
How does your child best express their needs and wants to others?
Equipment your child will bring to church:
AFOs, crutches, eyeglasses, hand/arm splint, hearing aids, helmet, walker, wheelchair, etc.
Does your child need help with eating? *
Does your child use the restroom without assistance?
Does your child display challenging behaviors? *
Behaviors that may communicate a specific need (please indicate the need where appropriate):
My child enjoys:
Check all that apply
Please describe your child's understanding of and relationship with God:
Goals for your child at church: *
My child is uncomfortable with or has sensitivities to:
It could include texture, sound, light, people, etc.
Please don't ask my child to:
My child participates more when:
Additional thoughts or concerns:
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