Special Needs Application | FBC Forney External

Child's First Name

Child's Last Name

Child resides with:

Dad Mom Both Other

Service Time: Sundays

9:15 AM 11:00 AM

Specific type of disability/disorder:

Check any of the following which apply:

Self-injurious Behavior G-tube Asthma Diabetes Physical Aggression ADHD Anxiety Seziure Disorder

Does your child require special equipment?

Is your child on medication?

Does your child have allergies? (i.e. food):

Eating/Drinking:

Bottle Assisted Self G-tube

Toileting:

Diaper Pull-Ups Assisted Self Change of Clothes

Communication:

Verbal Non-Verbal Picture/Symbol Assisted Technology Sign Language Follows Picture Schedule

Vision:

Vision Impaired Glasses Cane Braille Large Print

Auditory Impairment:

Hearing Aids FM System Cochlear Implant

Mobility:

If in a wheelchair or stroller, may they be taken out?

No Yes-chair Yes-floor Yes-beanbag Yes-all

Child's Birthday

What is your child's developmental age?

Reading level:

Writing level:

What are your child's strengths?

Weaknesses?

Fears?

Behavior requiring special management?

Please elaborate:

Control these behaviors by:

Are there any topic/words/phrases that should be avoided with your child?

Any words/or phrases to use with your child (for toileting, compliance, etc)?

What activities does your child enjoy most?

Does your child have a special interest, hobby or collection?

Please describe your child's understanding of God/relationship with Christ:

Previous church experience:

What would you like to see your child achieve from this program?

Any additional information to share with us?

Forms