Church of the Resurrection
Information document for individuals with special needs care plan
Today’s Date: ______
Full Name of Matthew’s Ministry child/youth/adult:
Date of Birth______
Family Information: Please print.
Address:______
City/State/Zip:______
Home phone #______Cell phone#______
Email: ______
Father’s Full Name ______
Home Address if different from above:______
Employer:______
Work Phone:______
Mother’s Full Name:______
Home address if different from above:______
Employer:______
Work Phone:______
If child lives with a caregiver, please list primary caregiver information, as well
Children Living at Home: Please list all children
Child #1: Full Name: ______
Male/Female:Date of Birth:
Name of School:Grade:
Child # 2: Full Name:
Male/Female:Date of Birth:
Name of School:Grade:
Child #3: Full Name:
Male/Female:Date of Birth:
Name of School:Grade:
Special Needs High School Graduates: Please describe your post high school education or employment:
______
______
Profile of Child/Youth/Adult with Special Needs
Briefly describe your child’s disability:
______
______
Contacts/Assistance in the Community:
Please list primary physician name, address and phone number:
______
Medical Information:
Procedures to follow in case of an emergency:
Health Insurance Co.______ID #______Group #______Hospital Preference______
*If you have a medical plan of care for emergencies, please attach a copy for us. The same plan that you have for school or a daycare provider is acceptable.
Please indicate your child’s height______and weight______.
Please list medications that are taken on a regular basis.
MedicationWhen TakenHow is it administered?
1.
2.
3.
4.
5.
Allergies to medications or environmental allergies (i.e. bee stings)
AllergySeverity of ReactionAction Steps
1.
2.
3.
Please list any medical or special precautions for managing the following concerns and please check any that apply and explain.
Seizures
G-Tube
Trach
Positioning
Respiratory
Communication Needs:
Can communicate with others using:
Speech: ___Words ___Phrases ___Sentences ___Babbles ___Gestures ___Sign Language
___ Other (describe______
Can understand what others say:
___ All the time ___ Most of the time ___Some of the time ___Recognizes voices of family
Dietary/Feeding Needs/Eating Habits:
Feeds by using: ___ spoon ___ fork ___ hands ___requires feeding ___bottle fed ___ drinks from cup: ___with assistance ___by self
Eating schedule:______
Special diet :______
Foods to avoid/Allergies to foods or medications:_____
If your child is difficult to feed, please describe any special assistance or adaptive utensils required for eating: ______
______
Toilet/Hygiene Needs:
___ Toilets independently ___Diapers:___Cloth ___Disposable
___ Currently being potty trained ___ Potty trained, needs assistance
___ Requires catheterizationFrequency/Schedule:______
How does your child indicate a need to use the toilet?______
______
Indicate special toileting needs/schedule:______
______
Behavior Management:
Check all that apply
___shy ___outgoing___is sometimes destructive
___plays alone ___plays in groups___sometimes threatens others
___adapts to new situations well___sometimes hits, bites or hurts self/others
___adapts to new situations with difficulty___sometimes attempts to run away
___responds to correction well___hyperactive and /or ADD
___responds to correction with difficulty
Behavior Concerns:
Please share any behaviors we should be aware of (i.e. aggressive behavior, tantrums, wandering):
______
Behavior Modification Plan: (May attach school management plan)
Please explain in detail the behavior management plan being used at home and school to modify inappropriate behavior that may be exhibited. Our goal is to maintain consistency in the implementation of this plan:
My child responds to separation from his/her parents by: ______
My child is best comforted by: ______
My child lets someone know what he/she wants or needs by:______
______
What type of play activities does your child enjoy or participate in? ______
______
My child becomes upset when/or does not enjoy:______
______
Are there any other concerns not already addressed? ______
______
Declaration of Consent
Please indicate your consent to each item by signing below each statement.
Emergency Medical Treatment Consent
I, ______, parent/guardian of ______give permission to the medical personnel selected by Church of the Resurrection to order hospitalization, treatment, anesthesia, and surgery if necessary in case of an emergency when parents cannot be reached.
SignatureDate
Photograph Release Consent
I, ______, parent/guardian of ______give Church of the Resurrection permission to use my child’s name and/or picture in presentations, media releases, newsletters and marketing materials solely for the purpose of promoting Matthew’s Ministry at Church of the Resurrection.
SignatureDate
Waiver of Liability Consent
I, ______, parent/guardian of ______agree to release Matthew’s Ministry of Church of the Resurrection and all 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 during the provision of respite care services.
SignatureDate