Calvary Champions: Child In-Take Form

Your name *

Email address *

Male or Female? *

Male

Female

Primary Contact Phone Number: *

Primary Contact Email *

Emergency Contact Phone Number *

How did you hear about us? *

In Service

Family Member/Friend

Youtube

Instagram

Facebook

Google/Internet

Church Email

Other

Medical and Functional History

Applicant's Primary Disability *

Current Medications (if none, type "N/A") *

List any potential medication side effects (if none, type "N/A") *

Does the applicant have seizures? (If so, please describe) *

Does the applicant wear glasses/contacts? *

Does the applicant have respiratory problems? *

Does the applicant have heart problems? *

Does the applicant need any one/one assistance? (If so, please describe) *

Our volunteers are unable to provide restroom assistance/medication assistance. If an accident were to occur, or if medication would need to be taken, then it is up to the parent/caregiver.

Please list any other medical concerns:

Speech and Cognition

This applicant communicates in the following ways: *

Non-verbal

Non-verbal but vocalizes

Scripting (i.e., uses rote phrases but decreased ability to communicate individual wants and needs)

Single words

Talks in sentences with decreased intelligibility

Fluidly uses words and phrases

Augmentative Communication Device

Sign language

Following Directions *

Is unable to follow most single-step directions

Follows contextual single-step directions

Independently follows one step directions

Follows two-step directions

Follows the majority of complex directions that are spoken to him

Does the applicant read? If so, at what level? *

Does the applicant write? If so, at what level? *

Does applicant have a current 504/IEP? *

Please list any sensory issues that your applicant has (if none, type "N/A") *

Does the applicant *

Walk independently

Use a wheelchair

Use braces

Walks independently but will fall on occasion

List any special positioning needs or mobility issues (If none, type "N/A") *

Please list any food allergies (if none, type "N/A") *

Please list any special food issues (if none, type "N/A") *

Does your child have difficulty swallowing? *

Yes

Please list any other dietary restrictions (If none, type "N/A") *

Activities of Daily Living

Toileting *

Independent

Wears diapers/pull-ups

requires assistance

Eating *

Feeds self

Requires assistance

Does the applicant have any of the following behavioral tendencies? *

Temper Tantrums

Running Away

Yelling

Biting others

Aggression towards others

Hitting

Self-directed/not yet participating in group structure

Pushing Others

Aversion to touch

Kicking

Pulling Hair

Throwing Items

Climbing on furniture

Eloping

Pulling out own hair

Biting self

Hitting head on hard surfaces

None

Other

If you answered other, please describe:

If you selected any of the behavioral tendencies, what usually precedes them? (What causes them to occur?) *

How do you handle this/these behaviors (if none, type "N/A") *

If so, please describe in detail (What causes it, how you handle it, etc.)

What is a consistently motivating context for the applicant to engage with others? *

What things/activities does the applicant enjoy engaging in by himself? *

What stimuli/contexts does the applicant dislike? *

When the applicant is upset, what helps to calm them down? *

Any special fears? (If none, type "N/A") *

How does the applicant respond/interact with peers? *

Please tell us about any sensory sensitivities (Visual, Auditory, Tactile, Movement/Touch) (If none, type "N/A") *

We should contact you during service if: (If none, type "N/A") *

Please provide any information that you feel is pertinent:

Before the applicant can attend the Champions ministry, the parent/guardian will need to sign the Parent Agreement Form at the Champions Check-In.

Person completing this form: *

Relationship to applicant: *

Type your initials if you have read and agreed to the previous statement: *

We Look Forward to Serving Your Champion!

To stay up to date, please join our Parents/Caregivers GroupMe! Here is the link:

https://groupme.com/join_group/100622632/NuZ82Fph