Parent Questionnaire for Children with Extra Needs
Summit Kids believes in an inclusive approach for any child participating in Children’s Ministry. Our desire is for every child to know they are welcomed, safe, and loved here. Our heart is for all children to know Jesus and grow in a relationship with Him!

We help determine the specific needs for each child and work with the family to develop a plan that is most beneficial for that individual child. We place a strong emphasis on each child’s strengths and abilities, not their disability. For some children, a 1:1 “buddy” may be provided to assist and support them during Summit Kids.

The following questions are asked for the benefit of your child so that we may provide them with the best experience and safest environment. We respect your family’s right to privacy. Any information shared through this form is communicated directly with those caring for your child and only on a “need to know” basis.

Email address *
Child's Name: *
Your answer
Date of Birth & Age: *
Your answer
Gender: *
Your answer
School & Grade: *
Your answer
Parent(s) Name: *
Your answer
Email: *
Your answer
Home Phone: *
Your answer
Cell: *
Your answer
1. My child has the following diagnosis, medical condition, or learning difference: *
Your answer
2. What are your child’s strengths: *
Your answer
3. What is your child afraid of or bothered by (clowns, loud noises, etc): *
Your answer
4. Ways to comfort or calm your child when angry or upset: *
Your answer
5. Please check any that are applicable to your child: *
Required
6. Any other concerns or information you would like us to know about your child? *
Your answer
Parent Signature: *
Your answer
Date: *
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**Our sensory room will be available to all students who may need a short break or a quiet place to go. Our special needs buddies (1:1) are trained on behavioral and crisis prevention strategies. They will not be providing any type of formal therapy, specific behavior modification programs, or medical interventions.**
A copy of your responses will be emailed to the address you provided.
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