2015-2016
Capernaum Young Life
White Bear Lake-Mahtomedi Area
Student Information Form
Students Name: (First) ______(Last)______
Parent(s) or Guardian(s) Name:______
Student Resides in: _____ Family Residence ______Group Home ______other, please list:______
Address:______
City:______Zip:______
Home Phone #: ______Work #:______
Parent/Guardian Name: ______Cell#: ______
Parent/Guardian Name: ______Cell#:______
Parent/Guardian E-mail Address :______( this is for e-reminders about events)
Student Date of Birth: _____/_____/_____ School: ______Grade Entry:______
Student’s Disability: ______
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Allergies? (i.e. medications, food, other) Yes_____ No_____ If Yes, Please List: ______
Does your son or daughter require one to one student to leader care? ______If not, what ratio would be helpful? ______*note: these ratios can’t always be met, but we will try our hardest to make sure they are. How did you hear about Capernaum? ______
What activities/hobbies does your son or daughter enjoy? ______
______
Please complete other side à
How can we best help your son or daughter enjoy Young Life Activities? ______
______
What type (if any) noises, activities, or situations bother your son or daughter? How is that irritation/anxiety displayed?______
______
______
If your son or daughter gets overly bothered or irritated, what are some ways to help him or her deal with and redirect the behavior? ______
______
Are there any physical activities or games your son or daughter can not take part in? ______
How do you encourage him or her to take part in a new event that he or she has not done before?
______
Other Helpful Comments/Accommodations (i.e. carries epipen/inhaler, special diet, will bring a PCA with to events, etc.) ______
______
*Note: There is always the option for parents/guardians to stay on site at the Young Life Office during programming at Golfview Gym.
Thank you for taking the time to fill this Information Form out. This really helps us know how to best serve your son or daughter. Please call or email the office if you would like to further discuss how we can make this a great year for your son or daughter. (651) 762-8483 or .