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.
Child's Name: *
Your answer
Child's Date of Birth: *
MM
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DD
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YYYY
Parent's Name:
Your answer
Parent Contact Email: *
Your answer
Parent Contact Phone: *
Your answer
My child has the following diagnosis, medical condition, or learning difference:
Your answer
My child has the following allergies and/or food sensitivities:
Your answer
My child’s main mode of functional communication is:
Your answer
The goals I have for my child’s development this coming year include (behavioral, social, academic, etc.):
Your answer
My child has the following area(s) of interest:
Your answer
My child can do these things independently:
Your answer
My child needs assistance with:
Your answer
My child is uncomfortable with or has an aversion to:
Your answer
A trigger-point for resistance, frustration, or behavioral problems may emerge for my child when:
Your answer
When/if my child experiences a period of frustration, he/she calms when we:
Your answer
Doing/seeing/experiencing this one thing is an important part of my child’s routine:
Your answer
My child does/does not enjoy music.
My child seems most relaxed in settings
My child (check one) would/would not enjoy a large group worship experience.
My child is prone to seizures
My child’s behavior may indicate a medical problem requiring immediate attention when:
Your answer
Other Information:
Your answer
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