Phone number *
Phone type Mobile Home Work Other
Household members
+ Add adult + Add child What are your child's favorites and strengths? *
ex. snacks, toys, activities, games, etc.
Please describe your child's disability/diagnosis. *
Are there any behavioral challenges we should be aware of? If so, please describe, and provide suggestions of how we may assist your child if these behaviors occur. *
Are there events or "triggers" that may be emotionally challenging for your child? If so, please describe, and provide suggestions of how we may help your child manage the situation. *
Which form of instruction best helps your child learn?
If other, please describe.
If your child currently attends a class in the community, would you describe the class setting as a: *
Is there a certain behavior your child exhibits to communicate a specific need?
Select… Yes No
What kind of assistance will your child need in class? *
Please list any potty training needs here.
Does your child need a "buddy" providing one-on-one supervision in class? *
Select… Yes No
Does your child use any of the following? *
Does your child have any medical conditions that the leaders need to be aware of?
Does your child have any seizures? *
Select… Yes No
Does your child need assistance with eating a snack in class? *
Select… Yes No
Is your child allergic to anything, including food allergies? *
Select… Yes No
If yes, would he or she like to wear noise reduction headphones during the music time?
Select… Yes No
Does your child have any of the following sensory sensitivities? *
Select… Light Tactile Odor Sound None
Is there anything else you would like for us to know about your child? *
Parent/Guardian Signature: *
Please fill in your first and last name.
I have completed the Access Ministry's Children's Intake for for my child and I hereby give permission to share the information on the completed Intake form with those who will be caring for my child who will be caring for my child at Northland Church. The information on this form is to be treated as confidential, but may be used to help the leaders to better understand how to minister to my child. I agree to update this information periodically upon request, and to inform the Access team leader of any changes in my child's needs.
Parent/Guardian Signature: *
Please fill in your first and last name.
Submit
