Register My Child

(Please list every diagnosis and beside each one put (M) mild (S) severe)

(Please make sure their name is own any item that will be brought for the Church program cannot be responsible for damage or loss.)

• Seizure Type and Nickname • What happens • How long it lasts • How often • Triggers • Other Seizure Treatments • Device Type • Dietary Therapy • Any Special Instructions

This includes medication that will not be taken during any event. We need this information in the event of any emergency only. If at any time any of this information changes in this year’s calendar please inform the program director or first aid nurse before attending the next event so we can update our records.

Please list the initial behavior, as well as the medical problem that follows.

(For example - Does your child/young adult need noise head muffs, small scale activities in a class room away from lights, energy, and noise or they would like a large group activity. List favorite color, sport, sports team, if they have a pet and pets name, if they play a sport, musical instrument, or in a club etc. This area is important for conversion purposes and so we can do activities liked and try and avoid ones that are not, be specific.)

Please list the initial communication, as well as the behavior that follows.