HOPE Special Needs of Grace Creek Church Registration and Medical Form
HOPE Special Needs of Grace Creek Church is available to individuals with special needs on a case-by-case basis where space is available. HOPE reserves the right to recommend other options, including GraceKids and RISE, if an individual does not fall within the parameters of the the special needs ministry at Grace Creek Church. For security purposes and because of the personalized care offered through HOPE, please email a recent picture of your loved one to hope@gracecreekchurch.com. In the subject field, please put “HOPE” followed by your loved one’s last name.
Individual's Name *
Your answer
Individual's Birthdate *
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YYYY
Individual's Age (Physically) *
Your answer
Individual's Age (Developmentally) *
Your answer
Individual's Current Weight *
Your answer
Individual's Special Needs and/or Diagnosis *
Your answer
Mother's Name *
Your answer
Father's Name *
Your answer
Home Address *
Your answer
City, State & Zip Code *
Your answer
Cell Phone Number (Mother) *
Your answer
Cell Phone Number (Father) *
Your answer
Home Phone Number (LAN Lines ONLY)
Your answer
Email Address(es) *
Your answer
Please answer the following questions as thoroughly as possible.
Can you describe your loved one's special need(s)? If so, what are they? Feel free to include your own conclusions. *
Your answer
Please describe your loved one's special needs by choosing from the following options: *
My loved one best responds to: *
Required
My loved one's normal disposition is: *
Required
My loved one's favorite toy or activity is: *
Your answer
My loved one REALLY DOES NOT like to:
Your answer
My loved one likes: (check all that apply) *
Required
Therapy Comforts: (check all that apply) *
Required
My loved one also likes: (check all that apply) *
Required
Behavior Issues *
Required
When my loved one is unhappy, the following things might calm him or her:
Your answer
Method of Communication: (check all that apply) *
Required
Social Behaviors: Does your loved one have any socially inappropriate behaviors? If yes, please describe.....
Your answer
What specific words of hand signals do you use to redirect your loved one? *
Your answer
Toileting (Caregivers bring necessary supplies) *
Required
Mobility: (Caregivers supply ambulation support) *
Required
Is your loved one a Runner? *
Medical Information
Does your loved one have seizures? *
If yes, are they life threatening?
What are the pre-indicators of their seizures? What are the effects after the seizure? (ie fixed staring, sleeping, headache, dizziness)
Your answer
Please list all current medications and doses (This information is for communication to medical personnel in emergency situations only).
Your answer
Medication Allergies *
Your answer
Any medication that has been changed in last 30 days?
Feeding ~ HOPE does not provide snacks. Caregivers are requested to bring necessary supplies. We have access to a microwave and a refrigerator. **NOTHING WITH PEANUT INGREDIENTS IS ALLOWED IN THE HOPE SUITE**
Special Feeding Issues *
Required
If you selected "Food Allergies" above, please list allergies here:
Your answer
Does your loved one have any tubes? *
Required
Is there anything else that would be useful for someone who cares for your loved one to know?
Your answer
**Atlanto-Axial Instability Assessment for Individuals with Down syndrome
Does this individual have Down syndrome? If yes, you must complete the area below. *
Has an x-ray evaluation for atlanto-axial instability been done? *
Positive Atlanto-axial Instability Results
Positive indication is the atlanto-dens interval is 5mm or more. I understand that if an individual has Down syndrome, he/she cannot participate in activities which by their nature result in hyper-extension, radical flexion or direct pressure on the neck or upper spine. By signing this form, I expressly warrant that this individual named above, is capable of withstanding both the physical and mental demands of various play activities.
If yes, was the x-ray positive for atlanto-axial instability?
Grace Creek Church recognizes there are many different attributes and conditions that an individual may demonstrate that fall into a category of special needs. Special needs can be defined as any condition causing an individual to have difficulty functioning in the ways that the world would deem as “normal.” The individual may have difficulty reading or comprehending, difficulty relating to other people in social situations, or difficulty with transitioning throughout the activities of an environment. Special Needs can be any individuals with medical, physical, mental and/or emotional special needs. “Special needs” is not defined by a diagnosis.
By submitting this registration form, I understand and consent to photographs/videos being taken and pictures of me and/or my family may be used for publicity, advertising, and promotion of Hope and Grace Creek Church. *
Required
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