Champions Student Intake Form Child's Name Date of Birth Age Diagnosis (This form allows us to provide the best experience and safest environment for each child within our ministry. Our church leaders and ministry volunteers will respect your family’s right to privacy. Any information shared is communicated directly with those caring for your child and only on a “need to know” basis.) Primary Caretaker Relationship to Student Primary's Phone Primary's Email Primary's Street Address, City and Zip Code Secondary Caretaker Relationship to Student Secondary's_Phone Secondary's_Email Secondary's Street Address, City and Zip Code Siblings: Names and Ages Child Information / My child loves to: Enjoys Music? Enjoys Music? Yes No Enjoys Writing? Enjoys Writing? Yes No Enjoys Arts & Crafts? Enjoys Arts & Crafts? Yes No Enjoys Reading? Enjoys Reading? Yes No Allergies/Food Sensitivities Allergies/Food Sensitivities Yes No If yes, please explain: Life Threatening? Life Threatening? Yes No EPI Pen? EPI Pen? Yes No Food/Drinks to Avoid: Prone to Seizures? Prone to Seizures? Yes No Other Medical Concerns: Toileting Needs Toileting Needs Independent Independent with assistance Wears diapers Signs, gestures, words to indicate toileting needs: Medication Medication Yes No if yes, please list medication type(s) and purpose: Main Mode(s) of Communication Main Mode(s) of Communication Verbal Visual Supports Sign Language Digital Devices My child is independent with: My child needs assistance with: My child is uncomfortable with or has sensitivities to: Behavior concerns to be aware of: Trigger-points for frustration / resistance: Calming tools and aids: Behaviors that may communicate a specific need (please indicate the need where appropriate): Classroom situations you wish to be contacted about: Please describe your child's understanding and relationship with God: Goals for your child at church: Ideas for the church to better serve your family: Additional thoughts or comments: Name of person submitting this form and date: 6 + 15 = Submit