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Journey Church
Additional Needs Ministry- Child Profile
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Child's Name
Your answer
Child's Age
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Child's Cognitive Age (if different than age)
Your answer
School Grade
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Gender
Male
Female
Date of Birth
Your answer
Parent's Name/s
Your answer
Child's Home Address
Your answer
Father's Cell Phone
Your answer
Mother's Cell Phone
Your answer
Email Address
Your answer
Siblings - Names, Ages, and Grades
Your answer
Diagnoses/Challenges (Please describe your child's diagnosis/challenges.)
Your answer
Strengths/Gifts (Please describe your child's strengths and/or gifts.)
Your answer
How can we best support your child at church?
Your answer
School Name
Your answer
Type of Classroom (Inclusion, Self-contained, etc.)
Your answer
Services Provided at School (Speech, OT, PT, ABA, etc.)
Your answer
Allergies - Drugs (If none, please type N/A)
Your answer
Allergies - Food (If none, please type N/A)
Your answer
Allergies - Other (If none, please type N/A)
Your answer
Describe Your Child's Current Health
Healthy
Fairly Healthy
Fairly Unhealthy
Unhealthy
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Chronic Health Problems (Ex. asthma, pressure sores, cough - list seizure information below)
Your answer
Any Health Treatments Staff Should Be Aware Of?
Your answer
Does Your Child Have Seizures?
Yes
No
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Current Medications (If none, please type N/A)
Your answer
Does Your Child have any physical conditions, past surgeries or injuries which restrict activity? (If none, please type N/A)
Your answer
Vision
Normal
Impaired
Blind
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Hearing
Normal
Impaired
Total Hearing Loss
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Speech
Normal
Impaired
Nonverbal
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Communication
Speech
Gestures
Sign Language
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Assistive Devices Used (If your child uses an assistive device, please send it with him/her to class if you feel like it will help his/her buddy communicate with him/her.)
Yes
No
Clear selection
Does your child understand what is being said to him/her?
Yes
No
Clear selection
Can your child speak in a way others can understand?
Yes
No
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Describe your child's communication skills.
Your answer
Mobility
Walks
Wheelchar
Walker
Scooter
Other:
Clear selection
If you selected other, please describe below.
Your answer
Toileting
No Assist
Partial Assist
Total Assist
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How does your child indicate the need to use the toilet?
Your answer
Describe special toileting needs/schedules.
Your answer
Can your child have snacks?
Yes
No
Clear selection
Please describe eating restrictions.
Your answer
How cooperative is your child?
Cooperative
Mildly reistive
Refuses
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How active is your child?
Not very active
Active like typical children
Overly active
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How does your child adapt to new situations/environments?
Well
Some Difficulty
Difficulty
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How does your child respond to correction?
Well
Some Difficulty
Difficulty
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Does your child exhibit behavioral challenges?
None
Destructive
Hits Self
Threatens
Runs Away
Bites Self
Hits or Bites others
Other:
Clear selection
If you selected other, please describe below.
Your answer
What is the frequency of the behavior challenges identified from above?
Your answer
What are successful strategies used to assist with the specified behaviors?
Your answer
What does your child enjoy?
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When does your child participate the most during the day/week?
Your answer
How is your child best comforted?
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What is your child's understanding of God/relationship with Christ?
Your answer
What have been your child's previous experiences with church?
Your answer
Does your child have a pet? If yes, what is the pet's name?
Your answer
Does your child have a favorite toy? if yes, what is the name of this favorite toy?
Your answer
Does your child have a responsibility, job, or hobby he/she enjoys?
Your answer
What else would you like us to know about your child?
Your answer
I understand that the information I am providing on this Journey Church Kid's World Inclusion Ministry Child Profile may be shared with Journey Church Kid's World ministry staff and approved Journey Church ministry volunteers. I also understand that this information I am providing will be secured with
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