Special Needs Ministry - Welcome Form

We’d love to learn more about you and your child so we can welcome you with care.

Your name *

Last name

Email address *

Household members

Please share information about each member of your family. Details about your special needs child will be collected below.

Which child has special needs? *

This child has the following diagnoses, medical conditions, or learning differences: *

Specific Care Needs:

Vision *

Hearing *

Motor Skills *

(check all that apply)

head control

rolls over

sits

crawls

walks

Please describe any assistive devices your child uses for mobility:

My child communicates with others using: *

speech

sign language

pictures

gestures

talking device

Other

Is there any information from your child's IEP or preferred style of learning that might be of help to us? *

My child is prone to seizures: *

yes

My child has food allergies or sensitivities: *

yes

Does your child use the restroom independently? *

yes

How does your child indicate they need to use the toilet? *

RESTROOM POLICY: For children that have moved up from our preschool department, if your child needs help going to the restroom or being changed, we will notify you to come to the room to assist him/her. If possible, please address these needs before drop off. We want you to be able to relax and have uninterrupted time in the service.

Behaviors

Does your child have any emotional/behavioral triggers that we need to know about to make sure they have a positive experience with us? *

What to Expect from My Child when interacting with others: *

shy

outgoing

prefers to play alone

adapts well to new situations

responds well to correction

difficulty responding well to correction

is sometimes destructive

sometimes threatens others

sometimes hits, bites, hurts self/others

sometimes attempts to run away

hyperactive

verbal outbursts

My child is best comforted by: *

My child's interests include: *

My child becomes upset with (or does not enjoy): *

Anything we missed? (avoidances, medical considerations, communication needs, etc):

Permission & Authorization Agreement

Please read the following statements carefully and initial in the designated space indicating that you have read, understand, and agree to the provisions.

I have fully disclosed to The Glade Church all pertinent facts about my child’s special needs and accept full responsibility for missing information. *

I will supply special food, drinks, snacks, and diapers/wipes for my child as necessary. *

agree

disagree

I will remain on The Glade Church campus during the time my child is participating in any ministry event/programming. *

Exceptions would be drop-off events including Parent’s Night Out, Respite Nights, or Vacation Bible School.

agree

disagree

For the child to attend the church activities, I acknowledge and accept the risks of injury associated with the child’s pre-existing condition while participating in church activities. *

I also acknowledge and accept the risks of injury or harm associated with intervention and/or treatment performed by church workers.

agree

disagree

On behalf of myself and my child, I agree to indemnify, defend, and hold harmles the church, and its agents, employees, volunteers, and other representatives for injury arising directly or indirectly out of the described medical needs of the child. *

agree

disagree

In a life threatening emergency, I authorize examination and/or treatment of my child by a physician or any health care professional for medical care and services deemed necessary by The Glade Church, its employees and representatives. *

I give the physician/health care professional permission to provide care, and agree to pay for any and all medical expenses incurred as a result of this consent. Parent will be contacted and involved as soon as possible

agree

disagree

I authorize The Glade Church to publish photos of my child (without his/her name) on our website and print material for promotional purposes only. *

agree

disagree

Today's Date: *

I have read and initialed the above permission/authorization statements and agree to the terms designated. *

Digital Signature

The Glade Church
615-444-9550