Special Needs Ministry Childcare Questionnaire

Let us make your child’s experience the best it can be.

At LifeSpring Church, we are committed to welcoming and supporting all children and families in our community, including those with special needs. We believe every child is a gift from God and deserves to be treated with dignity, compassion, and care. Our church and our children’s ministry workers respect your family’s right to privacy. Any information shared from this form will be communicated directly to those caring for your child on a “need to know” basis.

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

    Basic Information


    Child Name:
    Age:
    DOB:

    My child can eat snacks/treats provided by the church except the items identified belowMy child may only eat snacks I provide
    Please list dietary restrictions:
    Please list diagnosis or identification:

    The goals I have for my child’s development this coming year include:
    My child has these special interests:

    Developmental Areas: (please check all that apply)


    Communication

    My child... Speaks clearlyLimited verbalBabbles/GesturesSignsUses pictures or a device

    Comprehension

    My child understands what others say... All of the timeMost of the timeSome of the timeRecognizes familiar voices

    Vision

    My child... Wears glassesNeeds enlarged print materialsNeeds tactile materials

    Hearing

    My child... Slight impairmentAuditory processing difficultyWears aidsFunctionally deaf

    Physical/Motor

    My child...
    Has head controlSits unsupportedCrawlsWalks with supportUses crutchesUses a walkerUses a wheelchairWalks/runs independently
    Feeds selfFinger feedsIs spoon fedNo food/drink by mouthDrinks from a cupUses a strawUses a sippy cupDrinks from a bottle
    Independent in the bathroomWorking on toilet trainingNeeds help with clothing/fastenersNeeds assistance with transfersWears diapers/pull-ups

    Behavior

    My child has... Risk of elopementSeparation anxietyDifficulty with emotional regulation
    My child becomes upset when...
    My child can be calmed by...
    Some things that will help prevent behavioral outbursts are...


    Contact


    When should we contact a parent?
    Planned location of parent during services:
    9:30
    11:00

    Is there any additional info that will help us meet your child’s needs?



    Disclaimer: Limitations of Care and Support

    Our children’s ministry is primarily staffed by caring and dedicated volunteers who are not professionally trained in special education or medical care. Because of this, we want to be transparent about the scope of care we are able to provide. We may or may not be able to provide one-to-one supervision, medical, or bathroom/personal care. Support will be provided based on the availability of volunteers and resources. The safety of all children and staff is our top priority.

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