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Midland Evangelical

Free Church

Worship @ 9:00 & 10:45 AM

The Portal

Children with Special Considerations Intake Form

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Our church cares for each participant in BLAST Children’s Ministry.  These questions are asked for the benefit of your child so that we may provide the best experience and safest environment for everyone involved.  Our church and our children’s ministry workers respect your family’s right to privacy. Any information shared from this form is communicated directly with those caring for your child on a “need to know” basis only. 

Please answer the below questions that apply to your child and that may help our church best minister to your child.


Please fill out the fields in this section for the individual filling out the form:

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
*Prefix:
*Relationship to Child:

CHILD INFORMATION
* First Name:
* Last Name:
* Gender:
* Birthdate:
Address:
City:
State:
Zip:

SUPPORT INFORMATION
My child has the following health concern or learning difference (if you are not comfortable sharing this information please state "discuss in person")
My child's main mode of functional communication is
The goals I have for my child's development this coming year in BLAST Children's Ministry include (behavioral, social, etc.)
My child processes instruction or information best when (ie. visual, auditory, experiential, drama)
My child enjoys music:
My child seems most relaxed in the following settings:
My child is best comforted/calmed by
A trigger point for a potential meltdown is when
My child is uncomfortable with/has an aversion to
My child may be trying to communicate their need for (describe) when they exhibit the following behavior. (ie. If child grabs their throat they are asking for a drink)
My child has the following area(s) of interest:

AREAS OF ASSISTANCE
Please indicate whether your child is independent in or needs assistance with the following items:
Mobility:
Snack time:
Reading:
Communication:
Toileting:
If assistance is needed for toileting: Our policy is to have two adults present at all times during the care for your child, which includes assistance with toileting. Do you give us permission to help your child or change their clothing if needed?
Other areas of assistance needed (please list):

CARE NEEDS
Please indicate your child's care needs (check all that apply)
Vision:
Hearing:
Motor:
Additional information or explanation:

MEDICAL NEEDS
Please describe any special assistance or adaptive equipment
My child has the following allergies and/or food sensitivities:
*My child's allergies or medical condition can be life threatening:
If the individual has a life threatening allergy or medical condition please complete the Life Threatening Allergy & Medical Condition form. Please print this form and bring it with you on Sunday.
*My child is prone to seizures:
If the individual is prone to seizures please complete the Life Threatening Allergy & Medical Condition form. Please print this form and bring it with you on Sunday.
*If your child is prone to seizure, what prompts the seizure and how can we prevent/respond? (state n/a if not applicable)
My child's behavior may indicate a medical problem requiring immediate attention when...

FORM COMPLETION
Please include any additional comments or needs that you feel were not covered by this form:
You will be contacted within 48 hours of submitting this form online. The Safety4Kids and Special Programs Coordinator, JoDee Phillips, will connect with you to discuss supporting your child's needs in BLAST Children's Ministry.