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KL Special Needs Intake Form

When completing this form, please populate all responses with the child's information unless the field specifically asks for Parent or Guardian information. The only exceptions are the phone number & email address fields right below the LAST NAME field. Please enter Your phone number & email address in these fields. Thank you!
We hold to the biblical principle that all people have value because we are created in the image of God. Our goal is to provide children with special needs and their families a safe place to fully participate in the church because every child is a unique gift from God. Therefore, we provide individualized care and support to children with special needs and their families in the form of:
●    assistance during the Sunday 10:45 am Service 
●    assistance for children with special needs for any church sponsored activity

If you have a child or family member with a special need and are interested in visiting Christian Life Center, we would love to meet you!

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Birthday

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CURRENT Grade or KidsLife Class

Mother's Name (First and Last)

Father's Name (First and Last)

Foster Parent/Guardian's Name (First and Last), if applicable

APPROVED FOR PICK-UP
Please check ALL who may pick-up child.

If you check "Other" above, please specify:

SIBLINGS
Please enter each siblings name, date of birth, and grade.


FAMILY CONTACT INFORMATION

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Address Type

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Street Address

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City

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State

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Zip Code

Cell Phone Number (Mother)

Email Address (Mother)

Cell Phone Number (Father)

Email Address (Father)

Cell Phone Number (Foster Parent/Guardian)

Email Address (Foster Parent/Guardian)

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Emergency Contact Name (someone other than parents/guardians)

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Emergency Contact Phone Number

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Emergency Contact's Relation to Child

If you chose "Other" in the question above, please specify:


TELL US ABOUT YOUR CHILD'S STRENGTHS, INTERESTS, AND NEEDS

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Please tell us about your child's strengths. Go ahead, brag!

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Please list your child's interests. This helps us form relationships!

Does your child have a current IEP or 504 Plan? (For school-age children only.)

List the services your child is currently receiving both at school (if applicable) and privately. (Examples: aides, speech/language, counseling, social skills, PT, OT, Psychiatry, etc.)

Does your child have any specific sensory sensitivities?

Have there been any recent changes or stressors in your child's life that would be helpful for us to know about? (Examples: new baby, move to a new home, divorce, death, family illness, change of school, change of routine, etc.)

Please list any Foster Care requirements we should know about, if applicable.


Please identify your child's disability area(s). Check all that apply.

Use this space to tell us more about any disability area checked above (including others not listed above).

Please check any other health and medical needs that would allow us to best support your child and keep him/her safe.

Use this space to tell us more about any health or medical needs checked above.

Please give us any additional information that would make you feel comfortable as we work with your child.


TELL US ABOUT YOUR CHILD'S SKILLS AND TEMPERAMENT

Please select any tasks with which your child requires help. *
Please note: Nothing surprises us or makes us nervous, we just want to be prepared to welcome your child, keep him/her safe, and set everyone up for success at KidsLife.

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When my child gets angry he/she will:

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The best way to calm my child is:

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If my child needs the restroom, he/she will communicate by:

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My child needs some prompting to maintain attention or take turns. The best things to do are:

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I know my child needs a break when: 

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My child's understanding of God and his/her relationship with Christ is: 

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What spiritual goals do you have for your child?

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How can we partner with you and your family as you work together to grow in Christ?

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SPECIAL ACCOMMODATIONS CONSENT
I, the parent or legal guardian of this participant, grant permission for the participant to receive accommodations, equipment, and tools deemed necessary to allow him/her to participate fully in children/youth ministry activities and child care. I am familiar with the general goals and purpose of the special needs ministry. I understand I will be notified of any changes made to the participant's accommodations, equipment, and tools.  

Typing my name below signifies I understand and voluntarily agree to the above SPECIAL ACCOMMODATIONS CONSENT:

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ACCOMMODATION TO SAFE SANCTUARY POLICY
I, the parent or legal guardian of the participant named above, recognize that there may be times when my child needs immediate removal from an overwhelming environment to allow my child the space necessary for de-escalation. If there is an immediate need, I agree to allow my child to be one-on-one with a CLC volunteer, recognizing that this is an accommodation to CLC's Safe Sanctuary Policy. I also understand that I will be notified in the event my child is one-on-one with a CLC volunteer. 

Typing my name below signifies I understand and voluntarily agree to the above ACCOMMODATION TO SAFE SANCTUARY POLICY:

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EMERGENCY MEDICAL AUTHORIZATION, DISCLAIMER AND RELEASE
In an emergency when I cannot be reached at the phone number I provided, please contact the listed emergency contact. 

If the emergency contact cannot be reached either, I, the parent or legal guardian of the above-named participant, a minor, hereby authorize the staff, leaders, assistant leaders or chaperones of this event acting as activity supervisors/vehicle drivers to be my agents to consent to medical, surgical or dental examination and/or treatment of my child at any hospital or other medical facility. Further, I authorize any method of emergency transportation necessary, including but not limited to ambulance or private vehicle. I agree to pay any and all costs associated with the medical treatment and/or transportation of my child in case of an emergency. 

I, the parent or guardian of the above-named participant, acknowledge that participation in youth programs, events and/or activities necessarily involves risk of physical injury. I further acknowledge that the programs/events/activities of Christian Life Center (CLC) are primarily administered by volunteers, rather than paid professionals. 

In consideration for accepting the registration of the above-named participant and permitting the voluntary participation of said participant in its programs, I hereby release, discharge, and hold harmless the Ohio Ministry Network, Inc., Christian Life Center and their employees, any partnering churches and their employees, and those supervising the program/event/activity from any claims arising out of or relating to any physical injury or material loss that may result to said participant while participating in CLC programs/events/activities. I understand that adequate precaution will be taken for the safety of my child at all times. 

Typing my name signifies I understand and voluntarily agree to the above EMERGENCY MEDICAL AUTHORIZATION, DISCLAIMER AND RELEASE:


PHOTO RELEASE
I, the Parent or Guardian of the above-named participant(s), agree that the participant's picture and likeness can be used in marketing for this event, or other CLC events, including but not limited to the CLC website. This release will remain in effect until you cancel it in writing.

Typing my name signifies I understand and voluntarily agree to the above PHOTO RELEASE:

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