Office: 260-824-1844 / Email: info@hopemc.org

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Special Needs Intake Form

Phone

Basic information about the ALL4ONE participant and family:

Child's Name *

Child's Date of Birth *

Child's Grade *

Mother's Name

Father's Name

Guardian's Name

Approved For Pick-Up (check all that apply) *

Mother

Father

Guardian

Other

Siblings (Please list name, date of birth, and grade; if there are no siblings, please type N/A) *

Family Contact Information

Street Address *

City *

State *

Zip *

Cell Phone *

Provider

Email *

Emergency Contact Name (someone other than parents) *

Emergency Contact Phone Number *

Details About Your Child

Tell Us About Your Child's Strengths, Interests, and Needs (please tell us about your child's strengths, go ahead... Brag! This helps with relationship building between us and your child) *

Please check any/all health and medical needs that would allow us to support your child and keep him/her safe *

Disability

Seizures

Allergies

Food Sensitivities

Dietary Restrictions

Other Medical or Learning Issues

N/A

Use this space to tell us more about any needs you checked above *

Tell Us About Your Child's Skills & Temperament

Please check any tasks with which your child requires help.

(Please Note: Nothing surprises us or makes us nervous, we just want to be prepared to welcome your child, keep him/her safe, and set up everyone for success at Hope.)

Skills Temperament side 1

Remaining on Task

Understanding Directions

Eating

Staying in the Building

Reading Aloud

Making Friends

Using the Bathroom

Staying in the Class

Communicating

Skills Temperament side 2

Writing

Large Motor Skills

Small Motor Skills

Taking Turns

Staying Calm at Church

Managing a Large Space

Separating from Parents

Managing Loud Noises

Managing Crowds

When my child gets angry he/she will: *

The best way to calm my child is: *

If my child needs the restroom, he/she will communicate by: *

My child needs some prompting to maintain attention or take turns. *

I know my child needs a break when: *

What is your child's understanding of God and his/her relationship with Christ? *

What spiritual goals do you have for your child? *

How can we partner with you and your family as you work together to grow in Christ? *

Photo Release

I hereby grant, voluntarily and with full understanding, a license to the use and storage of still or moving images of my dependents, by means of digital or film photography, audio recording, or other documentation, with respect to ALL4ONE Ministries activities. *

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