Faith church of Worcester
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Faith kids: SPECIAL NEEDS request
Father's First Name
Father's Last Name
Mother's First Name
Mother's Last Name
Child's First Name
Child's Last Name
Child's Date of Birth
Child Lives With
Sibling/s names and ages (if applicable)
My child has the following diagnosis, medical condition or learning difference:
My child is prone to seizures
If yes, tell what prompts the seizure and how we can prevent/respond:
My child has the following allergies and/or food sensitivities:
Are the allergies life threatening?
Do you have an Epi pen with your child?
Does your child take medication?
If yes, what medications?
What special equipment does your child use, if any?
Child's fine motor skill disability level:
Child's gross motor skill disability level:
What are the primary ways that your child communicates with others?
How does your child indicate "yes" or "no" when asked if he/she wants something, wants to go somewhere, or wants a person?
Will child use other behavior(s) to communicate a want/need?
Uses toilet independently
Uses toilet with supervision
Follows a schedule
Wears a diaper/pull ups
Has bladder issues
Please share any signs or gestures that your child may give to indicate his/her need to be changed or go to the bathroom.
Please share with us about any behaviors of which we should be aware.
When do these behaviors typically occur?
Are they more likely to occur with a specific gender?
If yes, which gender?
Please explain the behavior management plan that is being used at home and school to modify inappropriate behavior that may be exhibited.
What is your child's response to separation?
What is your child's response to playing with other kids?
List activities, toys, or games that your child enjoys.
What are some positive activities, games, statements, or actions that are helpful to reinforce positive behavior?
Other important information