Sensory Room Application
Please fill out the information below.
Child's Name: *
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Child's Birthday: *
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Parent's Name: *
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Parent's Phone Number: *
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Additional Parent Name:
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Additional Phone Number:
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Which service does your family typically attend?
If your family attends a prayer room, please list the leader(s) of your prayer room:
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Please tell us a little bit about your child, including his/her strengths and motivations/interests. *
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What does your child enjoy about church?
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What is your child capable of during his/her time with us on Sunday mornings? What do you expect from him/her? *
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What could be too difficult or be an unrealistic expectation for your child? *
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What helps your child focus?
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If you feel comfortable doing so/feel that it is helpful, please list your child's diagnosis/diagnoses.
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Does your child have seizures? If yes, please explain. *
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Is your child currently in the foster care system? *
Are there any unique behaviors that we should be aware of? *
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Are there any triggers for these behaviors? *
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Please list the steps that you would like us to follow if your child's behavior has not changed after our efforts to redirect and encourage him/her.
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What are your expectations of our workers who interact with your child? *
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Do you think having access to the sensory room would be helpful for your child? *
Does your child currently receive Occupational Therapy services?
If your child used the sensory room, how could it help your child/what is your goal for the sensory room? *
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Which of the following are helpful for your child? *
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Which of the following are not helpful for your child? *
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Immanuel Kids is thrilled to staff the sensory room with two experienced volunteers during the 9am service. We also might need a third person, depending on how many families use the room. If you plan to use the sensory room during the 9am service, we ask that one IK approved adult from your household serve in a rotation. He or she will serve once every 4-8 weeks. Who is IK approved, or is willing to become IK approved, to serve in this role for your family? *
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We are thankful to offer this room to children who need it. In order to keep the space accessible to these children, we ask that siblings not enter the sensory room. Thank you! *
Is there anything else that you'd like to share with us? Do you have any questions?
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