Special Care Ministry

Please register for this ministry by filling out the information below, so we can better serve you and your child:

Child's First Name

Child's Last Name

Child's Birth Date

Parent/Guardian First Name

Parent/Guardian Last Name

Street Address

City

Zip Code

Email Address

Preferred Phone Number

Child's Diagnosis/Disability

Medications

Yes

No

Does he/she take these meds on weekends?

Yes

No

Does your child have allergies?

Yes

No

If yes, please list food and/or environmental allergies:

Please inform us of any medical needs we should be aware of (seizures, feeding tube, use of oxygen, etc.):

Is a nurse required?

Yes

No

Does your child have sensory or sensitivity needs?

Does your child have phobias or fears?

What behaviors might we encounter and what is the best intervention?

Is your child prone to running or biting or hitting?

Is there a special type of communication your child uses? Is there a specific language or words or actions that are used at home or at school?

What has been your child's greatest challenge in a social setting?

Does he/she have an IEP? (If yes, providiing it will better assist our buddies to meet your child's needs.)

Yes

No

Does your child need assistance using the restroom?

Yes

No

What kind of support has been successful for your child?

What activities does your child enjoy?

Any additional information you'd like to tell us about your child to better serve him/her?

Describe your child's past Sunday School/church experience:

What is your child's understanding of God/relationship with Christ?

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