Here - Breakaway

Special Needs
Family Registration 2015
Child’s Information
Child’s First Name
Child’s Last Name
Gender
M
F
Date of Birth
(must be 4 by 6/1/15)
Parent/Guardian Name
Home Phone
Alternative Phone
Child’s primary diagnosis and/or health concerns we should be aware of:
My child attends:
Granite Bay:
My child is attending: Breakaway Classic:
GB
Blue Oaks:
BOAK
FOL
Folsom:
Mid-Town:
MID Date________________ Extreme Games:
GB
BOAK
Care Needs
Vision:
Typical
Impaired
Blind
Hearing:
Typical
Impaired
Deaf
Hearing Aid
Motor:
Head control
Rolls over
Sits
Crawls
Walks
Wheelchair
Stroller
Sentences
Other (describe)
Babbles
Uses:
Walker
Crutches
Braces
Describe any special positioning or other needs your child may have:
Can communicate with others using:
Words
Gestures
Language spoken at home, if other than English?
Can understand what others say:
Recognizes voices of family members?
All the time
Yes
Phrases
Sign Language
Most of the time
No
Some of the time
Toileting Skills
Toileting:
Independent
Potty trained, needs assistance
Frequency Schedule:
How does your child indicate a need to use the toilet?
Any special toileting needs?
Diapers:
Cloth
Disposable
Currently being potty trained
Behavior
Check all that apply:
Shy
Outgoing
Plays alone
Plays in groups
Adapts to new situations well
Adapts to new situations with difficulty
Responds to correction well
Responds to correction with difficulty
My child responds to separation from his/her parents by:
My child is best comforted by:
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:
How long can your child stay engaged listening?
0-5mins.
Is sometimes destructive
Sometimes threatens others
Sometimes hits, bites or hurts self/others
Sometimes attempts to run away
Hyperactive and/or ADD/ADHD
Music
Storytelling
6-10min.
11-20mins.
Signature
Parent/Guardian Signature
X
Date
If you have any questions, please email Marcy Spina at 916-791-1244 ext.8533 or email [email protected]
PLEASE RETURN THIS FORM by one of the methods below:
Fax to Bayside Church at 916-791-5052
Drop off at the Breakaway Registration Table during any weekend service.
Drop off to Children’s Ministry Office at 8331 Sierra College Blvd, Ste. 216A, Roseville, CA
Mail to Bayside Church at P.O. Box 2336, Granite Bay, CA 95746
Art
Unable to sit