Connect Special Needs Intake Form

Please double check each item to ensure it is filled out correctly. We want to know how we can best serve you!

Your name *

Email address *

Form completed by *

Please type the name of the person completing this form

Child's Name *

Please type the name of the participant

What is the child's date of birth? *

Please select the Date of Birth of your child

Parent/Guardian Contact Information

Parent/Guardian Name *

Parent/Guardian Email Address *

Phone number *

Address *

Do you want to add another parent/guardian? *

Child Information

Please give us information about your child so we can best serve your family.

My child has the following diagnosis, medical conditions, or learning differences: *

Please list them below.

My child has the following allergies and/or food sensitivities: *

N/A for not applicable, please note the potential for an anaphylaxis type of reaction

My child's main mode of functional communication is: *

verbal, auditory, visually, etc

The goals I have for my child's development this coming year include: *

behavioral, social, academic, etc

My child has the following area(s) of interest: *

What does your child love to do?

My child can do these things independently: *

My child needs assistance with: *

Music time, snack, play time, restroom, crafts, peer interaction, or all?

My child is uncomfortable with or has an aversion to: *

any particular fears?

A trigger point for resistance, frustration, or behavioral problems may emerge for my child when: *

When/if my child experiences a period of frustration, he/she calms when we: *

Doing/seeing/experiencing this one thing is an important part of my child's routine: *

My child may be trying to communicate their need for _______________ when he/she exhibits the following behavior: *

what is the need and what is the behavior?

My child's behavior may indicate a medical problem requiring immediate attention when *

a particular repetitive behavior or tic?

Does your child enjoy music? *

My child seems most relaxed in a setting *

Please select only 1 option.

alone.

with a few children.

among many children.

Would your child enjoy a large group worship experience? *

My child is prone to seizures. *

Please provide any other information we may need.

Please read the below statement. By checking the box, you understand and agree with the below statement. *

The purpose of our church's special needs ministry is to connect the individual with special needs and their families to the life-changing gospel of Jesus Christ. We know there is no single way for a church to do special needs inclusion that will please everyone. However, we hope this ministry will be a blessing to you and your family. This is an opportunity for your entire family to attend church. While your dependent(s) is/are in Connect Special Needs, we provide the parent/guardian an opportunity to attend church. We need a parent/guardian to stay on the premises while their dependent(s) is/are participating in Connect Special Needs activities.

I hereby confirm that the information provided herein is accurate, correct and complete.
I understand that my child(ren) may be photographed at the church during normal church hours or activities. I understand that these photographs may be used in promotion, either in print or on the Internet. I acknowledge giving consent to Connect Church to take, own, and use images containing your child(ren)'s likeness at Connect Church's sole discretion, in perpetuity. Please inform a staff member immediately if your child's photograph cannot be taken.

I hereby release and forever discharge Connect Church, the Ridge Outdoor Resort, and the Ridge Event Center, their staff, representatives, and affiliates from any physical or psychological injury that my child(ren) may suffer as a direct result of participation in Connect Church Special Needs activities. I recognize participation in these activities and am voluntarily participating in them in recognition of potential risks.

Please sign this digital form by typing your name. *