Grace Life's Special Care Ministry: Initial Form

Child's name *

Gender *

Birthdate *

Grade

Parent/Guardian name(s): *

Phone number *

Address *

Names & ages of siblings *

Does he/she have any medical information we need to know about? (diagnosis, allergies, etc) *

Does he/she have any medical equipment that requires a trained assistant?

Describe your child's strengths *

Will your child need assistance when it comes to eating? *

Does your child have any food sensitivities or prefer specific snacks/drinks?
Does your child have a G-tube?

What are your child's favorite activities or interests? *

(This helps us form relationships!)

Please check any task with which your child may need assistance. *

using the bathroom or diaper/pull-up changes

managing in loud environments

transition/separating from parents

communicating with others

staying in the classroom

understanding directions

none of the above

Help us understand how we can best support your child when they become upset. *

"If my child is upset or needs a break, he/she will..."
"The best way to calm my child is..."

Does your child exhibit any of the following behaviors? *

may hurt self (biting, scratching, pinching, hitting head or self)

may hurt others (biting, scratching, pinching, hitting)

runs away

none of the above

In regard to the previous question, how often do these behaviors occur: never, seldom or often? Please be as specific as possible. What do you do when any of these behaviors occur? Leave blank if no behaviors occur.

How can we come alongside your family? *

How can we partner with you and your family as you work together to grow in Christ?
What do you want your child to get out of Special Care Ministry?
How can we support or assist your child's siblings?

Is there any additional information we need to know that would help us best care for your child?

(avoidances, communication needs, etc)