Adapted class intake form

This form is designed specially for kids that have special needs. It is to collect need to know information to ensure their child has the support they need in the right class. All infomation collected is private and will only be shared as required and with the permission of the guardian.

Your name *

Last name

Email address *

Child's name *

Gender

Birthdate

Grade

Address

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Phone number

Phone type

My child has the following diagnosis, medical condition or learning difference

What is their communication method?

Verbal

Limited Verbal

Non-Verbal

Uses sign language

Uses a communication device

Do they have triggers or stressors that we should avoid?

Noise

Lights

Touch/textures

Crowds

Smells

Other

Does your child? *

If 4 or more are checked, our Stars class will be the best fit for your child!

Requires constant supervision for safety

Displays agressive or self injurious behaivor

Has complex medical needs requirng trained staff

Frequently overwhelmed in group settings (meltdowns/shutdowns)

Unpredictable behaivor that affects group safety

Requires help with toileting, feeding, mobility

Has a formal diagnosis indicating severe cognitive or intellectual delay

Please explain the help your child will need while in class

How does your child best respond to instructions or correction?

Gentle verbal prompts

Visual cues

Physical prompts (with permission)

Needs 1:1 attention

Does your child? *

Needs help staying on task

Struggles with transitions or change in routine

Uses a device or limited verbal communication

Needs frequent breaks or calm down space

Experiences sensory overload in large groups

Has social delays and needs help making or keeping friendships

Has a diagnosis of autism, ADHD or other learning/processing challenges but functions well in supported environments

What is the best ways to comfort or redirect your child?

Mobility

Walks independently

Use wheelchair/walker

Needs assistance navigating space

Other

Has your child attended kids ministry before?

Yes

If yes, describe any experiences (positive or challenging)

What would you like your child to experience and learn at CLC Kids?

Is there anything else that would be helpful to know to be successful with your child in CLC Kids?

At CLC Kids our comittment to parents is that their child with special needs will know how much they are loved by God and important to him! *

Our standards of practice are, As a parent you understand that we as a childrens' ministry are here to ensure the safety and wellbeing of our volunteers and children. If there is a concern in the classroom, we will need you to return to the kids wing immediately. We do not use restraints or punishments in our classrooms at any time unless it is to maintain the safety of others.

I understand this information will be used only to support my child’s experience in CLC Kids Ministry and kept confidential.

Parent/Guardian Signature:
Date:

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Calgary Life Church
office@calgarylifechurch.com
403.239.9099