Child's Information
First Name
Last Name
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
Year
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Gender
Male
Female
I'd rather not say
Child's Diagnosis
Family Information
Mother's
First Name
Last Name
Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Email
Lives in home with child
Yes
No
Father's
Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Email
Lives in home with child
Yes
No
Sibllings'
Siblings name and ages
Getting to Know your Child
My child loves
Enjoys music?
Yes
No
Enjoys arts and craft?
Yes
No
Enjoys outside?
Yes
No
Enjoys writing?
Yes
No
Enjoys writing?
Yes
No
Enjoys reading?
Yes
No
Allergies/Food Sensitivities?
Yes
No
If yes, please explain.
Life threatening?
Yes
No
Epi Pen?
Yes
No
Assistance needed for eating/drinking?
Yes
No
Prone to seizures?
Yes
No
If yes please explain.
Toileting needs:
independent
with assistance
wearing diapers/pull-ups
Sign, gestures, words to indicate toileting needs:
Medication?
Yes
No
If yes, type and purpose:
Main mode of communication:
verbal
visual supports
sign language
digital device
My child is independent with:
My child needs assistance with:
My child needs assistance with:
Behavior concerns to be aware of:
Calming tools and aids:
Behaviors that may communicate a specific need (please indicate the need where appropriate)
Classroom situations you wish to be contacted about:
Please describe your child's understanding of and relationship with God
Goals for your child at church:
Ideas for the church to better serve your family:
Additional thoughts or comments:
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