BELONG KIDS: CHILD INTAKE FORM

PARENT/GUARDIAN INFORMATION:

Parent/Guardian Name:

Phone Number:

Email Address:

Preferred Method of Contact:

Text Call Email

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Relationship to Child:

CHILD INFORMATION:

Child's Name:

Date of Birth:

Age:

Grade:

School:

Siblings in Church:

ABOUT YOUR CHILD:

What are some things your child enjoys?

What are your child's strengths or gifts?

What helps your child feel comfortable and successful?

What are some things that may cause frustration, anxiety, or sensory overload?

MEDICAL & SAFETY INFORMATION:

Does your child have any diagnosed conditions or disabilities we should be aware of?

Does your child have any allergies?

No Yes

If yes, please explain:

Does your child have any medical concerns we should know about?

Does your child take medication that may affect participation?

No Yes

If yes, please explain:

SENSORY & BEHAVIORAL SUPPORT:

Does your child have any sensory sensitivities?

Noise Bright Lights Crowds Touch Transitions

Other sensory sensitivities:

What helps calm or regulate your child when upset?

Are there specific strategies that are especially effective?

BATHROOM & PERSONAL CARE:

My child is:

Fully Independent Needs Occasional Assistance Needs Regular Assistance

Additional information:

PARTICIPATION & SUPPORT:

Can your child safely participate in a group setting?

Yes With Support No

Would your child benefit from a one-on-one buddy?

Yes No

Has your child previously participated in a special needs ministry?

Yes No

If yes, what worked well?

SPIRITUAL INFORMATION:

Has your child made a profession of faith in Jesus Christ?

Yes No Unsure

How can we best help your child grow spiritually?

Are there any Bible stories, songs, or activities your child especially enjoys?

ADDITIONAL INFORMATION:

Is there anything else you would like us to know about your child?

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Thank you for helping us get to know your child. The information provided helps us create a safe, welcoming, and supportive environment where your child can fully participate in Belong Kids.

BELONG KIDS: CHILD INTAKE FORM

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