Intake Questionnaire
Access cares for each participant inside LC Kids. These questions are asked for the benefit of your child, and so that we may provide the best experience and safest environment for everyone involved. Our church leaders and our ministry volunteers respect your family’s right to privacy. Any information shared from this form is communicated directly with those caring for your child and only on a “need to know” basis. Please answer the below questions that apply to your child and that may help our church best minister to your child.
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Child's Name: *
Child's Date of Birth: *
Parent's Name:
Parent Contact Email: *
Parent Contact Phone: *
My child has the following diagnosis, medical condition, or learning difference:
My child has the following allergies and/or food sensitivities:
My child’s main mode of functional communication is:
The goals I have for my child’s development this coming year include (behavioral, social, academic, etc.):
My child has the following area(s) of interest:
My child can do these things independently:
My child needs assistance with:
My child is uncomfortable with or has an aversion to:
A trigger-point for resistance, frustration, or behavioral problems may emerge for my child when:
When/if my child experiences a period of frustration, he/she calms when we:
Doing/seeing/experiencing this one thing is an important part of my child’s routine:
My child does/does not enjoy music.
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My child seems most relaxed in settings
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My child (check one) would/would not enjoy a large group worship experience.
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My child is prone to seizures
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My child’s behavior may indicate a medical problem requiring immediate attention when:
Other Information:
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This form was created inside of Loudonville Community Church. Report Abuse