The Buddy Ministry Intake Form below should be completed by a parent or guardian. Thank you!Help us get to know your child with special needsYour child's name *Your child's age *Your child's grade *GenderMaleFemaleChild lives with:One parentBoth parentsGuardianFather's/Guardian's Name *Father's/Guardian's Cell # *Father's/Guardian's Email Address *Mother's/Guardian's Name *Mother's/Guardian's Cell # *Child's diagnosis, medical condition or learning difference that we should be aware of: *A goal for my child while participating in the Buddy Program is:Section 2: Care NeedsVision *TypicalImpairedBlindHearing *TypicalImpairedDeafHearing AidMotor *WalkerCrutchesBracesWheel ChairCan Communicate with others using: *WordsPhrasesSentencesBabblesGesturesSign LanguageOtherIf "other" was selected in the previous question, please describe that here:Language spoken at home:Can understand what others say:All the timeMost of the timeSome of the timeRecognizes voices of family membersSeizuresIs your child prone to seizures?YesNo**If "Yes", please fill out and send a "Seizure Action Plan"Allergies and/or Sensitivities (food, drug, other): *Feeds self by using:SpoonForkHandsRequires feedingBottle fedDrinks from cupSpecial diet:Toileting skillsToilets independentlyDiapersCurrently being potty trainedPotty trained, needs assistanceFrequency/ScheduleHow does your child indicate a need to use the toilet?Indicate special toileting needs/schedule:Behavior (check all that apply)"ShyOutgoingPlays alonePlays in groupsAdapts to new situations wellAdapts to new situations with difficultyResponds to correction wellResponds to correction with difficultyIs sometimes desctructiveSometimes threatens othersSometimes hits, bites, or hurts self/othersSometimes attempts to run away or wanderHyperactive and/or ADDYour child responds to separation from his/her parents by:Your child processes instruction or information best when (ie: visual, auditory, experiential learner):A trigger point for a possible "melt down" is:When my child experiences a "melt down" he/she calms when we:My child is best comforted by:My child may be trying to communicate their need for (describe)when he/she exhibits the following behavior:My child lets someone know what he/she wants or needs by:What type of play activities does your child enjoy and/or participate in?My child becomes upset when/or does not enjoy:Are there any additional concerns not already addressed:Permission Authorization AgreementPlease read the following statements carefully and choose "I agree" in the designated space indicating that you have read, understand and agree to the provisions.I have fully disclosed to Reynoldsburg Community Church all pertinent facts about my child's special needs and accept full responsibility for missing information.I agreeI do not agreeI will supply special food, drinks, snacks, and diapers/wipes for my child as necessary.I agreeI do not agreeI will remain on church campus during the time my child is participating in any ministry event/program, unless it is specifically designated as a "Respite Event".I agreeI do not agreeI understand the nature of the program and do hereby release Reynoldsburg Community Church and its representatives from any liability due to accident or injury incurred by my child.I agreeI do not agreeI authorize Reynoldsburg Community Church to publish photos of my child (without his/her name) on the church website and brochures for promotional purposes only.I agreeI do not agreeI have read and agreed the above/authorization statements and agree to the term designated in each:(please type your name)DateSubmitPlease do not fill in this field.
