Special Needs Ministry Data Form

Special Needs Ministry Data Form

NEW FAMILY ____ UPDATED FAMILY ____

Child’s Full Name: ______Age: ______Grade: ______

Parent or guardian full name: ______Cell Phone: ______

Child’s Diagnosis

Please check all that apply and degree of severity.

Comments:

ADD/ADHD / Mild: / Moderate: / Profound:
Autism / Mild: / Moderate: / Profound:
Cerebral Palsy / Mild: / Moderate: / Profound:
Developmental Delay / Mild: / Moderate: / Profound:
Down Syndrome / Mild: / Moderate: / Profound:
Emotional Disability / Mild: / Moderate: / Profound:
Hearing Impaired / Mild: / Moderate: / Profound:
Language/Speech Disorders / Mild: / Moderate: / Profound:
Learning Disability / Mild: / Moderate: / Profound:
Physically Disabled / Mild: / Moderate: / Profound:
Visual Impairment / Mild: / Moderate: / Profound:
Other (Please describe):

Briefly describe any details about your child’s disability:

______

Please list and explain any medical or special concerns: (Seizures, G-tube, Epi-Pen, Positioning, etc.)

______

Dietary Needs

My child CANNOT eat these foods due to allergies or diet restrictions:

______

Mobility

Please list any mobility requirements or special equipment:

______

Communication

Please list any communication needs? (Verbal, Non-verbal, Sign, etc.)

______

Behavior

My child: (Check all that apply)

___Shy___Outgoing

___Prefers to play alone___Prefers to play in groups

___Sometimes destructive___Sometimes threatens others

___Adapts to new situations well___Adapts to new situations with difficulty

___Sometimes hits, bites or hurts self/others___Sometimes attempts to run away

___Responds to correction well___Responds to correction with difficulty

Please share any additional behavior concerns we should be aware of:

______

Please explain any behavior plans being used at home/school to modify behaviors that may be exhibited: Our goal is to maintain consistency in the implementation of this plan and work with you in the process.

______

Sensory Needs

Checkmark all that apply to your child:

__ Sensitive to bright lights__ Seeks touch from objects and/or from others

__ Sensitive to loud noises__ Cannot sit still in his/her chair

__ Tends to avoid excessive movement__ Often puts objects in his/her mouth

__ Seeks frequent movement__Typically lethargic or sleepy throughout the day

__ Sensitive to jumping/ falling__Difficulty paying attention

__ Sensitive to spinning__ Anxious or afraid of enclosed spaces

__Sensitive to touching particular objects or consistencies__Prefers to be alone or in enclosed spaces

Please list comments or share any additional sensory needs:

______

Please share your child’s interests/activities:

______

Any other comments? ______

______

Photograph Release Consent

I, ______, parent/guardian of ______give Calvary Church permission to use my child’s name and/or picture in presentations, media releases, newsletters and marketing materials solely for the purpose of promoting Calvary Kid’s SEEDS.

Signature Date

Waiver of Liability Consent

I, ______, parent/guardian of ______agree to release Calvary Kids Ministry of Calvary Church (along with staff and volunteers involved) from all liability for any additional illness or injury to my child, and for any accidental damage or destruction of my child’s property during the provision of respite care services.

Signature Date