Faith church of Worcester
Home
About Us
Our Story
Our Beliefs
Staff
Elders
Good News
Contact
Next Steps
Plan Your Visit
Get Baptized
Become a Member
Serve
Outreach
Connect
Church Events
Faith Kids
Men
Women
Care Groups
Prayer
Give
Sermon Archive
Watch Live
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
Gender
Male
Female
Grade
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Developmental Age
Child Lives With
Both Parents
Mom
Dad
Guardian
Sibling/s names and ages (if applicable)
Email
Phone Number
My child has the following diagnosis, medical condition or learning difference:
My child is prone to seizures
Yes
No
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?
Yes
No
Do you have an Epi pen with your child?
Yes
No
Does your child take medication?
Yes
No
If yes, what medications?
What special equipment does your child use, if any?
Child's fine motor skill disability level:
Mild
Moderate
Profound
Child's gross motor skill disability level:
Mild
Moderate
Profound
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?
Toilet/Hygiene Skills:
Uses toilet independently
Uses toilet with supervision
Needs assistance
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?
Yes
No
If yes, which gender?
Male
Female
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
Submit