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Special Needs Ministry of HRBC

Please fill out the first part as the parent/guardian and the rest for the child.

Your name *

Last name

Email address *

Child's Name *

Preferred Name

Diagnosis *

Family Information

Household members

Please list anyone within the household and contact info for guardians.

Details About Your Child

Tell us about your child's strengths, interests, and needs. This information will help us build a relationship with your child and help us better serve your family.

My child has the following diagnosis, medical condition or learning difference:

My child's main mode of functional communication is...

My child loves to...

My child enjoys music

Yes

My child would enjoy a large group worship experience.

Yes

Medical note

Does your child have any allergies or food sensitivities? If yes, please explain.

If your child does have allergies or food sensitivities: Is it life threatening?

Yes

Does your child carry an EPI Pen?

Yes

Is your child prone to seizures?

Yes

Any other medical concerns?

Toileting Needs

Independent

Needs Assistance

Wears Diapers/Pullups

Signs, gestures, words to indicate toileting needs:

Please list the things that your child can do independently.

Please list the things that your child needs assistance doing.

My child is uncomfortable or has sensitivities to:

The trigger points for frustration/resistance with my child are:

The best calming tools/aids for my child are:

Some behaviors that may communicate a specific need for my child may be:

Classroom situations that you wish to be contacted about:

Goals for your child at church:

Ideas for the church to better serve your family:

Media consent *

Do you as the parent/guardian grant, voluntarily and with understanding, a license to use and storage of still or moving images of your child by means Do you hereby grant, voluntary and with full understanding, a license to the use of digital or film photography, audio recording, or other documentation, with respect to Hickory Ridge Baptist Church?

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Hickory Ridge Baptist Church
info@hickoryridgebaptist.org
601-845-3548

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