Child & Family Information
Transcription
Child & Family Information
Child & Family Information Date:_________Name___________________________________DOB________Grade________ Family Information Mother ______________________________ May pick up child? Father _______________________________ May pick up child? Yes Yes No No Other Children ________________________ DOB ____________ Grade in School ___________ Custody concerns ______________________________________________________________ Contact Information Address _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Home Phone ________________________ Cell Phone(s) ______________________________ Email ________________________________________________________________________ Please tell us about your child’s strengths: (Go ahead…BRAG!) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please list your child’s interests: (This helps us to form relationships.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please tell us about any health and medical needs that would allow us to best support your child and keep him/her safe: (Circle/explain) Epilepsy_______________________________________________________________________ Food Allergies__________________________________________________________________ Food Sensitivities________________________________________________________________ Other medical or learning issues____________________________________________________ Child & Family Information Please give us any additional information that would make you feel comfortable as we work with your child. ______________________________________________________________________________ ______________________________________________________________________________ Please circle 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 up everyone for success at church. Remaining on task Making friends Understanding directions Using the bathroom Eating Staying in the class Staying in the building Communicating Reading aloud Writing Large-motor activities Small-motor activities Taking turns Separating from parents Staying calm at church Managing loud noises Managing a large space Managing crowds Other Help us understand the above issues by completing the following phrases: When my child gets angry or upset, he/she will _______________________________________ ______________________________________________________________________________ The best way to calm my child is ___________________________________________________ ______________________________________________________________________________ If my child needs the restroom, he/she will communicate by ____________________________ ______________________________________________________________________________ My child needs some prompting to maintain attention or take turns. The best things to do are ______________________________________________________________________________ ______________________________________________________________________________ I know my child needs a break when _______________________________________________ ______________________________________________________________________________ How can we partner with you and your family as you work together to grow in Christ? _______________________________________ Parent Signature ______________ Date Child & Family Information This resource is provided FREE of charge by the team at Key Ministry. Please let us know how we can support you and your ministry. Our team provides the following resources to churches FREE of charge… o o o o o o o Best Practices Online Resources Opportunities to network with other churches Phone & Skype Consultation On-site Consultation & Training Celebrating your successes Local & National Conferences Praying for you! Please keep in touch! We would LOVE to hear from you. Key Ministry 8401 Chagrin Road, Suite 14B Chagrin Falls OH 44023 Phone: 440/247.0083 www.keyministry.org www.FREERESPITE.com If you’ve been blessed by our ministry we would love for you to consider supporting our mission financially. You can donate today by visiting our website or you can scan this code with your smart phone to view our Key Catalog. Thank you for your support!