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Special Needs Ministry Introduction Form

Thank you for helping us understand your child/adult better. We appreciate as much detail as you can provide!

Your name *

Last name

Email address *

Phone number *

Phone type

Which campus do you plan to attend? *

If your child/adult has never attended our Special Needs Ministry, what date do you plan to visit?

What phone number would you like us to text should we need you during service? *

Household members

Tell us about your Child/Adult.

What is your relation to this child/adult? *

Parent

Guardian

Sibling

Friend

Caregiver

Other

My child/adult has the following diagnosis, medical condition or learning differences: *

Autism

Developmental Delay

ADD/ADHD

Down Syndrome

Sensory Processing Delay

Seizure Disorder

Other

What food allergies or sensitivities does your child/adult have? *

None

Gluten/Wheat

Tree Nuts

Peanuts

Milk/dairy

Red Dye

Egg

Soy

Fruit

Other

Are there any other food or drink concerns we need to be aware of?

Please Describe.

How does your child/adult best communicate his/her needs? *

S/he is verbal

S/he uses signs

S/he uses picture cards

S/he uses a talker (electronic communication device)

Other

How does your child/adult best receive communication from others?

S/he understands verbal language

S/he understands signs (simple to complex)

S/he uses picture cards

Other

Tell us what your child/adult needs help with:

Following directions

Toileting

Washing hands

Interacting appropriately with others

Staying in the designated area

Attending to activities for more than 5 minutes

Other

Does your child/adult have any particular aversions?

Please Describe.

Are there particular calming strategies that are helpful for your child/adult?

Please Describe.

Does your child/adult tend to run away (elope)? *

Yes

Other

Are there any specific behaviors we might see during our programs in which your child/adult might be trying to communicate something particular? What might s/he be trying to tell us?

Please Describe

Are there any medical situations your child/adult may experience and attempt to communicate with us?

Please Describe

Is there any other pertinent information we should know as we care for your child/adult?

Please Describe.

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Rocky Mountain Christian Church
info@rocky.church
303-652-2211

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