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 Name *
Student's Date of Birth *
MM
/
DD
/
YYYY
Address *
City, State, Zip *
Email *
Emergency Phone 1 *
Emergency Phone 2 *
What are your child's hobbies/ interests?
Diagnosis *
Significant Medical History (Surgeries, hospitalizations, illnesses, etc.) *
Allergies *
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: *
Required
Does he/she toilet independently? *
If no, explain.
Is he/she on a toileting schedule? *
If yes, explain.
Mobility. Please choose all that apply: *
Required
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
Submit
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