Child Enrollment

Child's Information

First Name

Last Name

Birthdate

Gender

Age and Grade

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

Father's

First and Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Email

Sibllings'

Lives in home with child

Siblings name and ages

Getting to Know your Child

My child loves

Enjoys music?

Enjoys arts and craft?

Enjoys outside?

Enjoys writing?

Enjoys reading?

Allergies/Food Sensitivities?

If yes, please explain.

Life threatening?

Epi Pen?

Assistance needed for eating/drinking?

Prone to seizures?

If yes please explain.

Toileting needs:

Sign, gestures, words to indicate toileting needs:

Medication?

If yes, type and purpose:

Main mode of communication:

My child is independent 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:

Family Information

Getting to Know your Child

Sundays

Contact

Location

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