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: