Request edit access
Ability Tree First Coast CHILD PROFILE
This online child profile form is for our Ability Tree MVPs (children with special needs). However, if you feel the sibling(s) need a profile completed as well, certainly complete one, but it's not required.

IMPORTANT: Completing this child profile does not secure a spot for any program. You will want to complete the registration form with payment (if applicable) to reserve the spot through Eventbrite.

Also, please complete our ATFC Waivers (https://goo.gl/6i6fPS ) for all children attending any activities/events and return to info@abilitytreefc.org. The waivers need to be opened in Adobe Acrobat because they are in writable pdf format and allow you to sign electronically. If you have any issues with completing these waivers, please notify us through our email.

**One profile & waiver packet per child, please.**

Email address *
Child's First and Last Name: *
Date of Birth: *
MM
/
DD
/
YYYY
Child’s maturation/cognitive age: *
Primary Disability Diagnosis (and Secondary, if applicable): *
Please describe diagnosis (use as much detail as you feel would be beneficial):
Parental/Guardian Information
Guardian's Name (First & Last) *
Relationship to child *
Best contact phone number (may provide more than one number) *
In case of an emergency and you can't be reached, who should we contact? (Provide First & Last Name and Relationship) *
Emergency contact phone number *
Names of siblings & ages (if applicable)
MEDICAL INFORMATION
Physician's Name & Medical Group: *
Physician's Telephone #: *
Preferred Hospital: *
Insurance Company:
Policy #:
Policy Holder:
Medical Diagnosis:
Does your child have seizures? (If yes, provide type, duration, & frequency.) *
Are seizures controlled with medications? (Skip if not applicable)
Clear selection
Food Allergies (if none, please write N/A): *
Other Allergies (if none, please write N/A): *
CHILD'S ABILITIES & SKILLS
How does your child communicate? (Please check all that apply) *
Required
Your child can understand what others say: *
What's your child's form of mobility? *
Required
Does your child require assistance eating? (If yes, please explain.) *
Does your child have special dietary needs? (If yes, please explain.) *
Foods your child really likes: *
Foods your child really dislikes: *
Does your child have bladder control? (If not, please explain, ie wears pullups/diapers.) *
Does your child have bowel control? (If not, please explain, ie wears pullups/diapers.) *
Does your child need potty reminders? *
Does your child need assistance during toileting? (If yes, please explain.) *
For females: Does your child need assistance during menstruation? (If yes, please explain.)
BEHAVIORS
What behaviors pertain to your child? (Check all that apply) *
Required
Circumstances when these behaviors occur (if applicable):
What do you typically do to remedy the situation (if applicable)?
ACTIVITIES
How would you describe your child’s approach to new situations? *
How is your child best comforted? *
How would you transition your child to new activities (i.e. five-minute warning, no warning, etc.)? *
What activities does your child like to do (i.e. music, coloring, independent play, etc.)?
My child needs encouragement to:
Please do not ask my child to:
Does your child have any fears? (Check all that apply) *
Required
How do you deal with these fears at home?
OTHER THINGS TO KNOW
Child's pet's name & type of pet (if applicable):
Child's favorite toy:
Siblings Name(s) & age(s):
Any additional information you feel would be important for staff to know about your child:
Thank you for taking the time to complete your child's profile.
Each profile is reviewed to make sure we are able to create a setting that takes your child's abilities & needs into consideration for a time of fun! We want to set your child up for success, as well as our staff & volunteers.
Submit
Never submit passwords through Google Forms.
This form was created inside of Ability Tree First Coast. Report Abuse