Special Needs Child Form
Answers are not going to be shared and are confidential.

Information is being collected to help JCFamilies in the planning of activities and events.

If you have more than one chid with special needs, please fill one individual form for each.

Gender *
Age of the Child *
Your answer
Child's Guardian Name *
Your answer
Child's Guardian Email *
Your answer
Is the child enrolled in a school? *
If yes, where?
Your answer
Is your child receiving therapy in the school? *
Is your child receiving therapy outside the school? *
What kind of activities would you be interested in enrolling your kid? *
What other extracurricular activities does your child attend? *
Your answer
What would you prefer? *
Please briefly explain your child's needs: *
Your answer
Preferred time for playdates: *
Preferred length for playdates: *
Does your child have needs for motor, social , sensory regulation, or behavior interventions? *
Is your child potty trained? *
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