Register My Child Special Needs Participant Intake Form Name First Last Date of Birth Child/Young Adult lives with:MomDadGuardianBoth ParentsGroup Home/AgencyIs there someone that the Child/Young Adult should never leave an event with?Medical Diagnosis/Learning Differences:(Please list every diagnosis and beside each one put (M) mild (S) severe)What Medical Equipment will your child/young adult be bringing with them to a Church Event:(Please make sure their name is own any item that will be brought for the Church program cannot be responsible for damage or loss.)Health Risk for your child/Young adult:Is your child/young adult is prone to seizures?YesNoPlease provide additional seizure information below:• Seizure Type and Nickname • What happens • How long it lasts • How often • Triggers • Other Seizure Treatments • Device Type • Dietary Therapy • Any Special InstructionsList all Medications taken below:MedicationDosageAM/PM 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.My Child’s/young adults behavior of ________________may indicate a medical problem requiring immediate attention when:Please list the initial behavior, as well as the medical problem that follows.Snack/Eating Issues: (Please explain: are they on a specialized diet or they cannot take anything by mouth, tube fed, choking precautions, or some examples)Allergies and/or Food sensitivities: Please be very specific in this area. There is a huge difference between preparing for and reacting to a severe allergic reaction, and a food sensitivity or recommended diet. Please explain in detail if there would be concern for an anaphylaxis type reaction and if there is an EPI Pen or medication that you will be leaving with the nurse. Explain emergency procedure to follow if needed. For ex. - Cannot have sugar.What assistance does your child/young adult need in the restroom? Wears a diaper Wears a pull up Uses a urinal Needs assistance in wiping Possibility of Fecal smearing Additional information about restroom assistance:What are your child/young adults interests/likes/dislikes/fears/joys?(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.)What can your child/young adult do alone? (Be specific)What does your child/adult need assistance to do? (Be specific)Behavior: Explain what applies to your child/young adult.Behavior: Check all that apply to your child/young adult. Outgoing or shy Plays in Groups Hyperactive and/or ADD Adapts to new situations well Adapts to new situations with difficulty Responds to corrections well Responds to corrections with difficulty Sometimes is destructive Sometimes threatens others Sometimes hits, bites; will throw things or hurts self/others Sometimes attempts to run away Anxious Content Difficulty following instructions Prefers to play alone Needs private sensory area total time Needs private sensory area but can join group for short activities Problems making friends Problems keeping friends Hyperactivity ODD (Noncompliance) Pica Additional Information concerning your child/young adult behavior:What are trigger-points that may result in resistance, frustration, or behavior problems?When/if my child experiences a period of frustration, he/she calms when we:My child may try to communicate their need for (describe)__________________ when he/she exhibits the following:Please list the initial communication, as well as the behavior that follows.Communicates with: (Check all that apply) Words Phrases Sentences Babbles Gestures Sign Language Shakes head yes or no Syllables Single words Braille Facial expression Body language Picture/Visual strategies Symbol system eye gaze Partner assisted scanning texture cues Touch cues Can Understand what others say:All of the timeMost of the timeSome of the timeRarely Minimal or no understanding only recognizes familiar voicesAdditional information: explain any needs or information that will be important to us providing care for your child/young adult.Please explain if there are any activities that your child/young adult cannot participate in:Signature of Person Completing this form:Relationship to the Child/Young Adult:Generations Church respects your family’s right to privacy, this information is will be used only for the need to know bases so we can provide care for your child/young adult so everyone involved can have a positive experience in a safe environment. Please take the time to fill out All areas of information with as much information possible. If there is an IEP, ISP, or behavior plan that you can share with us, This information will benefit us to prepare for activities involving your family member. Please delete any personal information that we do not need. Thank you, Program Director This iframe contains the logic required to handle Ajax powered Gravity Forms.