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Student/Child Information

Access Ministry Providence Baptist Church


Thank you for filling out this form. We respect your familys privacy and will only use this information for ministry purposes. The information in this form is shared only with those involved in caring for your child so they will know and understand any special care needs. Participation is dependent on availability of volunteers. Student Name:_________________________ Birth Date:___ /____ /_________ Gender: M F

Fathers Name:_________________________ Cell Phone:__________________ Email:____________ Mothers Name:________________________ Cell Phone:__________________ Email:____________ Home Phone:______________________

The following information will help us understand your childs needs. Thank you. We are so grateful that God brought your family to join us at Providence! _______________________________________________________________________ Diagnosis and Special Needs
Does your child have a specific disability/diagnosis of special need? Diagnosis and description in lay terms: No Yes

Is your child taking a medication with possible side effects we should be aware of? Name of medication and possible side effects: Seizures? No Controlled Uncontrolled If seizures occur, please describe: Respiratory problems? No Frequency:

No

Yes

Yes Please describe:

Food/Drinks we should not give your child: Does your child have any allergies that we should be aware of? Assistance needed when eating/drinking? Toileting: Independent No No Yes Please list:

Yes please describe: Requires assistance Type: Uses braces or orthotics

Wears diaper/pullups

Mobility: Walks independently Uses wheelchair Any positioning or mobility concerns: Please provide any other important care instructions:

Communication and Cognition


The student communicates in the following ways: Non-verbal, but vocalizes Says words Talks near or at typical level for age The child can understand what others say: Recognizes voices of family members Talks in sentences, but may be hard to understand Uses sign language Which signs? All the time Other: Most of the time Some of the time

Following directions: Is unable to follow directions Follows simple one-step directions Follows two-step directions Has no trouble following directions Receives Special Education in school? No Yes Included in typical classroom Some inclusion in typical classroom

No Inclusion

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Social and Behavioral
Childs understanding of God/relationship with Christ: Past Sunday School/Church experience: What are your childs strengths? How is your child similar to his/her same-age peers? How is your child different from his/her same-age peers? What things or activities does your child like? What things or activities does your child dislike? Behavioral tendencies: Temper tantrums Pushing Running away Aversion to touch Yelling Biting Other: Hitting

Refusal to follow directions

Withdrawal

How do you handle this/these behavior(s)?

What suggestions do you have for including your child? (For example, sit closer to the teacher, dont ask him to read aloud, avoid loud noises and so on.)

We should contact you if:

Please provide any other information that might be helpful for us to know.

_____________________________________________________________
Permission and Authorizations PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY & INITIAL IN EACH SPACE INDICATING THAT YOU HAVE READ, UNDERSTAND, & AGREE TO THE PROVISIONS.
_______ I have fully disclosed to Providence Baptist Church all pertinent facts about my childs special needs and accept full responsibility for missing information. _______ I will supply special food, drinks, snacks, and diapers/wipes for my child as necessary. _______ I understand the nature of the program and do hereby release Providence Baptist Church and its representatives from any liability due to accident or injury incurred by my child. _______ I authorize Providence Baptist Church to publish photos of my child (without his/her name) on our website and brochures for promotional purposes only. I have read and initialed the above permission/authorization statements and agree to the terms designated in each: Parent/Caregiver:________________________________________ Date / /

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