Special Needs: Circle of Friends - Fellowship Alliance Chapel

Address

Birthdate

Gender

Specific Type of Disability/Diagnosis *

It is very important that you are thorough for us to be able to accommodate you and your child's needs.

Please be sure to include any medical and/or developmental conditions.

Parent/Guardian/Caretaker Name(s) *

Sibling Name(s)

Student's Medical Information

Does your child/student take Medication. *

Yes

No

Any Medical and/or Food Allergies? *

Yes

No

Student's Developmental Information

Any Social/Emotional behaviors that we should be aware of? *

Yes

No

Any Frustration Triggers that we should be aware of? *

Yes

No

How does the student learn best? *

Visual

Auditory/Music

Kinesthetic (Movement)

Large Group

Small Group

Other (Explain Below)

Student's School Information

Where does the student attend school? *

What age/grade is the student? *

Does the student have an IEP/504 *

Yes

No

What devices and/or accommodations are used in the classroom? *

It is very important that you are thorough for us to be able to accommodate you and your child's needs.

Additional Information

Any additional information that we should know? *

It is very important that you are thorough for us to be able to accommodate you and your child's needs.

May we use photographs and/or videos for communication with you and your family? *

Yes

No

May we use photographs and/or videos for church promotion? *

Yes

No

Comments

Please tell us anything you would like to see happen in the ministry, or ask any questions you may have. We will be sure to respond promptly.

I understand that any information given is to be used to help my family connect to God, and will only be shared with his/her teachers or buddies who work directly with my child. *

I authorize emergency medical treatment for my child in the event that I cannot be contacted and it is deemed necessary by any of the staff and/or volunteers at Fellowship Alliance Chapel, and the staff at any hospital where they might receive treatment. *

Please type full name

I certify that all the above information is true and correct to the best of my knowedge. *

Plese type full name

I have fully disclosed to Fellowship Alliance Chapel all pertinent facts about my family member's needs, and I accept full responsibility for any failure to do so. *

Please type full name

It is my understanding that in the unlikely event that my child might become injured, or cause an injury, while participating in the SNOW ministry programs, that I assume all risks and liability associated with that injury. *

Please type full name