Child Information Form
Email address *
Guardian Name *
Child's Name *
Nick Name *
Status *
Date of Birth *
MM
/
DD
/
YYYY
Child's Age *
Length of time in your care (if not biological child) *
Child's History (please check any known) *
Required
Comments
Diagnoses, Disabilities
Indicate any behaviors or conditions below that the Fundango staff should know about:
How might this impact functioning at Fundango?
Are there things that will trigger certain behaviors with this child? Explain *
How does this child like to be comforted? *
Does child engage in inappropriate behavior to get attention? If yes, please describe.
Does the child interact appropriately sexually? *
Are there any concerns about sexual behavior or issues? Explain
Are there special social/public guidelines to be aware of and enforce? Explain.
Should the siblings be separated? *
Should the child be separated from any other Kids at Heart participant?
Clear selection
MEDICAL & HEALTH INFORMATION
Please update with Fundango staff if changes occur after completing this form.
Any allergies? *
Required
If yes, explain. Also list any special diets or foods.
SIGNATURE
By signing below you agree information contained is to the best of your knowledge. Please update the Kids at Heart staff if something changes that will impact our ability to provide a safe, healthy and pleasant environment for the child while in our care.
Signature of Legal Guardian / Parent / Foster Parent (type your name) *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Kids @ Heart. Report Abuse