Special Needs Ministry Information Form

Your name *

Email address *

Phone number *

CHILD/STUDENT'S NAME (FIRST AND LAST) *

GRADE (IF APPLICABLE)

Address *

CHILD/STUDENT LIVES WITH *

SIBLINGS LIVING AT HOME (NAMES AND AGES)

PRIMARY CAREGIVER'S NAME (IF DIFFERENT FROM ABOVE)

RELATIONSHIP TO CHILD/STUDENT

Mother

Father

Other

PRIMARY CAREGIVER'S CELL (IF DIFFERENT FROM ABOVE)

PRIMARY CAREGIVER'S ADDRESS (IF DIFFERENT FROM ABOVE)

PRIMARY CAREGIVER'S EMAIL (IF DIFFERENT FROM ABOVE)

EMERGENCY CONTACT NAME (OTHER THAN PARENTS OR CAREGIVER) *

RELATIONSHIP TO CHILD/STUDENT *

WITH WHAT DISABILITIES HAS YOUR CHILD/STUDENT BEEN DIAGNOSED? *

ADD / ADHD

Autism

Cerebral palsy

Developmental delay

Down syndrome

Emotional disability

Hearing impaired

Intellectual disability

Post-traumatic stress disorder

Seizure disorder

Sensory processing disorder

Speech / language disorder

Visual impairment

Other

IF OTHER PLEASE DESCRIBE:

SCHOOLING *

Home School

Attends School

Does Not Attend School

SCHOOL NAME (IF APPLICABLE)

RECEIVES SPECIAL EDUCATION IN SCHOOL *

Yes

Not Applicable

RECEIVES 1:1 SUPPORT *

Yes

Not Applicable

INCLUDED IN TYPICAL, AGE-APPROPRIATE CLASSROOM *

All day

Part of the day

Not Applicable

CLASSES THAT CHILD/STUDENT IS INCLUDED IN (IF APPLICABLE)

SELF CONTAINED CLASSROOM

Learning support

Emotional support

Person with Autism support

Life skills

Other

RECEIVES ADDITIONAL THERAPY / SUPPORT SERVICES? *

Yes

Not Applicable

TYPE OF THERAPY SUPPORT (IF APPLICABLE)

COMMUNICATION / COGNITION (CHECK ALL THAT APPLY) *

Verbal

Non-verbal

Follows two-step directions

Uses sign language / gestures

Uses assistive technology (picture boards, communication device, etc.)

Wears hearing aids

MOBILITY (CHECK ALL THAT APPLY) *

Walks independently

Uses a wheelchair

Uses braces or orthotics

Falls on occasion

CAN EAT SNACK PROVIDED *

Yes

LIST SPECIAL DIETARY NEEDS (I.E. PUREED, GLUTEN-FREE, ETC.) *

EATS BY MOUTH *

Yes

USES SPECIAL UTENSILS OR CUP *

Yes

REQUIRES SUPERVISION WHILE EATING

Yes

LIST ALL FOOD AND OTHER ALLERGIES. IF NONE, INDICATE N/A. *

HAS YOUR CHILD/STUDENT EXPERIENCED SEIZURES? *

Yes

HYGIENE *

Uses bathroom independently

Uses bathroom with supervision

Needs transfer assistance

Follows a schedule

Needs prompts/reminders to use bathroom

Wears a diaper - parent/caregiver will be called for assistance

Feminine needs - parent/caregiver will be called for assistance

IF NON-VERBAL, LIST SIGNS OR GESTURES THAT MAY INDICATE THEIR NEED TO USE THE BATHROOM:

SOCIAL BEHAVIOR / INTERESTS / PREFERENCES

MY CHILD/STUDENT IS (CHECK ALL THAT APPLY) *

Shy

Outgoing

Prefers to be alone

Enjoys being in a group

Initiates interactions on his/her own

Needs support in connecting with others

Likes being the center of attention

Prefers not to be recognized publicly

Adapts to new situations well

Adapts to new situations with difficulty

ACTIVITIES YOUR CHILD/STUDENT ENJOYS AND / OR PARTICIPATES IN: *

MY CHILD/STUDENT BECOMES UPSET WHEN OR DOES NOT ENJOY: *

WHAT BEHAVIORAL TENDENCIES DOES YOUR CHILD/STUDENT HAVE? (CHECK ALL THAT APPLY) *

Wandering/Elopement

Yelling

Biting

Hitting

Pushing

Throwing

Refusing to follow directions

Sometimes destructive

Aversion to touch

Repetitive talking/gestures/actions

None of these

Other

WHAT RESPONSES ARE MOST EFFECTIVE FOR YOUR CHILD/STUDENT ONCE A BEHAVIOR HAS OCCURRED? *

MY CHLD/STUDENT IS BEST COMFORTED BY: *

WHAT PROACTIVE STRATEGIES ARE HELPFUL IN PREVENTING THESE BEHAVIORS? (CHECK ALL THAT APPLY) *

Verbal feedback for appropriate behavior

Frequent breaks (short walk, drink, etc.)

Physical gestures ("high 5," pat on the back, handshake, etc.)

Choice of preferred activities following appropriate behavior

Redirection

Sensory activities

Picture/written schedules

Fidget toys/transitional objects/manipulatives

Support during transitions

Periodic individual attention from caregivers

Fewer demands

Decrease in sensory input (noise, talking, visual stimulation)

Limitations on tools (i.e. no scissors, sharp pencils, glue, etc.)

Other

LIST ANY SENSORY ACTIVITIES THAT MAY BE PROACTIVE IN HELPING PREVENT THESE BEHAVIORS:

FOR WHAT SITUATIONS DO YOU WISH TO BE CONTACTED? *

WHAT HOPES / DREAMS DO YOU HAVE FOR YOUR CHILD/STUDENT ATTENDING OUR CLASS? (FAITH-BASED, SOCIAL, BEHAVIORAL, ETC.)

CONSENT, RELEASE, & MEDICAL AUTHORIZATION / RELEASE OF LIABILITY FORM

Recognizing the risk associated with the operation of a ministry for individuals with a disability and the possibility of physical injury or loss, the below named parent/s of the above-named individual hereby agree to the following during the duration of his/her participation in the class.

CONSENT, RELEASE, & MEDICAL AUTHORIZATION

1. Blanket Permission: I hereby grant permission for full participation in any or all of the activities that are held on-site with the Special Needs Ministry of Grace Christian Church, Georgetown, KY (the "Church") during the period commencing with the date of this form.
2. Release: I understand that the Church staff and adult supervisors will endeavor to provide individual care and safety for each participant in each activity and/or program. I am aware that neither the Church nor any member of its staff or adult supervisors can assume responsibility for any injury or damage, which may occur in connection with such program or activity. Therefore, by signing below I am agreeing to the Legal Release of Liability and the Indemnification of the Church, which are set forth on this form and incorporated herein by reference, by which I am releasing and/or holding harmless the Church, its staff, and volunteers from any liability incurred by the Church arising out of any Church-sponsored activity in which he/she participates.
3. Medical: I also give my consent, approval, and authorization for Church staff or other adult supervisors to authorize emergency medical treatment if reasonably deemed necessary by them.

LEGAL RELEASE OF LIABILITY & INDEMNIFICATION

The Parent hereby:
a. Agrees to review all the information provided by the Church concerning any Church sponsored activity, and agrees to the precautions planned for the safety and care of the participants;
b. Acknowledges that, notwithstanding the exercise of reasonable safety precautions, participation in any Church sponsored activity involves certain actual and potential risk(s) of loss;
c. Releases the Church from all liability for any loss incurred by the participant or by the Parent arising out of or related to any Church sponsored activity, except for loss due to the Church's willful misconduct, and
d. Agrees to indemnify and hold the Church harmless from any liability for loss incurred by the Church (1) as the result of injuries to the participant or (2) due to the acts of the participant, occurring in the context of any Church related activity.

As used herein, the term "Loss" means personal injury, sickness, loss of life, or damage to or loss of property, real or personal; "Church" means Grace Christian Church, Georgetown, KY, its Governing Board, Pastors, and staff, its leadership supervisors, volunteers, and members; and "Parent" means the parent(s) or legal guardian(s) of the participant identified above.

Parent represents, warrants, and agrees that by signing this form the Parent has full legal authority to do so; that the Parent has legal custody of the participant; that the approval and agreement of any other parent or guardians has been obtained by Parent, and that the undertaking herein shall be binding upon the Parent, and other Parent or guardian, the participant, and their respective heirs, personal representatives, and assigns.

As of this date, I affirm that the information given on this form is true and accurate, and I hereby also grant my assent to the Consent, Release, & Medical Authorization/Release of Liability form. *

Yes

PARENT/LEGAL GUARDIAN'S NAME *