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Special Needs Intake Form
Contact Information
Name of Individual with Special Needs
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
- Please Select =
Male
Female
Name of Person Completing this Form
*
Relationship to Individual
*
Phone
*
Email
*
Enter Email
Confirm Email
Needs
We would like to give your child/teen/adult the best experience possible in our Special Needs Ministry. If you are able, please provide some helpful information by answering the questions below so that we are aware of how to best serve your loved one.
Special Needs
*
Does the individual have any of the following needs: behavioral, cognitive, physical, or communicative, of which we should be aware?
Yes
No
Special Needs Details
Please provide any relevant details regarding needs.
Does the individual have any allergies?
*
Yes
No
Allergies
Please list all allergies.
Is the individual prone to seizures?
*
Yes
No
Seizures
Please provide any relevant details regarding seizures.
Likes/Dislikes
Please tell us about the individual’s likes and dislikes.
Toileting
If toileting issues arise, the parent/caretaker will be texted.
Name
This field is for validation purposes and should be left unchanged.
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