Child Information Form
Email address *
Guardian Name *
Your answer
Child's Name *
Your answer
Nick Name *
Your answer
Status *
Date of Birth *
MM
/
DD
/
YYYY
Child's Age *
Your answer
Length of time in your care (if not biological child) *
Your answer
Child's History (please check any known) *
Required
Comments
Your answer
Diagnoses, Disabilities
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How might this impact functioning at Fundango?
Your answer
Are there things that will trigger certain behaviors with this child? Explain *
Your answer
How does this child like to be comforted? *
Your answer
Does child engage in inappropriate behavior to get attention? If yes, please describe.
Your answer
Does the child interact appropriately sexually? *
Are there any concerns about sexual behavior or issues? Explain
Your answer
Are there special social/public guidelines to be aware of and enforce? Explain.
Your answer
Should the siblings be separated? *
Should the child be separated from any other Kids at Heart participant?
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.
Your answer
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) *
Your answer
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