FC Special Needs Participant Intake Form

This form serves as the initial step for parents who would like to sign a child up for our Special Needs program specifically designed to accommodate children who have a need for adaptive learning or behavior strategies. This program will provide a safe experience for such children with trained volunteers.

Your name *

Email address *

Phone number *

Address *

Relationship to child who will be in our program *

Special Need Child's Name: *

Gender *

Birthdate *

(This program is only for kids who are preschool or elementary age)

Diagnosis *

What makes your child a candidate for our special needs program?

Additional Health Concerns

List allergies here or any other information we may need

Can your child communicate verbally? *

Yes

Other

Tell us about your child's physical activity level and abilities below: *

Tell us about your child's cognitive ability or special learning accommodations needed below: *

Ability to understand the lesson

Tell us about your child's social abilities and how they relate to their peers below: *

Tell us about your child's ability to regulate his/her emotions below: *

Please include any tips or tricks that help your child to regulate his/her emotions

Select any behavioral challenges that your child potentially faces *

Select all that apply

Runs Away when upset

Screams/ yells

Aggressive to self (scratches, bites, hits, pulls hair)

Aggressive to others (scratched bites hits, pulls hair)

May say inappropriate words/phrases

No behavior challenges at this time

Reinforcers or correction plan used for behavioral challenges: *

Select all that apply

Use this box to tell us a little more about any other behaviors of your child that would help us to know about:

Can you attend the 9:30 service on a Sunday morning?

(We currently are offering our Champions program at or 9:30 Service only)

Would you be willing to serve occasionally in our Special Needs room at 9:30? *

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