Special Needs Intake Form - LifePoint Church

Special Needs Classroom *

This information will be kept in our church database and and a printed copy kept in the Special Needs classroom and accessed by our KidPoint staff and dream team members as needed to best care for your child.

What campus do you plan to attend? *

Address *

Phone Number *

Child's Information *

Child's name, birthday, gender, and grade (if applicable)

Medical and Functional History *

Child's primary diagnosis / disability

Seizures: *

Yes

No

Respiratory problems *

Yes

No

Allergies *

Yes

No

If Yes what are they?

Heart Problems *

Yes

No

Vision Problems *

Yes

No

Sensory Issues *

Yes

No

If Yes what are they?

Dietary Concerns *

Yes

No

If Yes what are they?

Child Communicates by *

Nonverbal

Says words

In sentences by hard to understand

Uses a communication board

Uses sentences and easy to understand

Uses a computer- assisted device

Other

If Other Please Explain

Child is not so strong in: *

My Child Likes: *

My Child does not like: *

Behavioral Tendencies: *

Temper Tantrums

Running Away

Yelling

Biting

Hitting

Aggression

Refusing to follow directions

Pushing

Aversion to Touch

Other

How Do You Handle Behavioral Tendencies *

Please tell us how you would like your child to grow and learn about God while in the Special Needs room: *