The Hangout Intake Form
This intake form is required for students attending The Hangout at Abundant Life Church. Answering the questions on this form will allow Hangout workers to best care for your student. This information will remain confidential.
Optional: A picture of your child for our volunteers to familiarize names and faces!
Student's Date of Birth
City, State, Zip
Emergency Phone 1
Emergency Phone 2
What are your child's hobbies/ interests?
Significant Medical History (Surgeries, hospitalizations, illnesses, etc.)
Respiratory Deficiencies (Please Explain)
Has your child had any seizures in the last year?
If yes, when? Types? Frequency? Duration?
What is the preferred caregiver response?
Communication/Sensory Impairments. Please choose all that apply:
Points to objects named
Uses generalized gestures and sounds
Uses sign language
Single words or sounds
Phrases or short sentences
Can he/she follow simple directions?
Does he/she toilet independently?
If no, explain.
Is he/she on a toileting schedule?
If yes, explain.
Mobility. Please choose all that apply:
Crawl, Scoot, Roll
Use Wheelchair (Motorized or Manual)
Please list anything we need to know about your child
Please list any triggers
Please list what helps your child work through his/her meltdowns
Please list any additional emergency contacts
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service