VIP Intake Form

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VIP Intake Form

Caring for Those with Special Needs

These questions allow us to provide the best experience and safest environment for all of our friends within the ministry. Our church leaders and ministry volunteers will respect your family's right to privacy. Any information shared is communicated directly with those caring for your family member and only on a "need to know" basis. If you have any questions please contact VIPbuddies@valenciahills.com for more information.

I'm interested in... *

A buddy for my K-12 VIP

VIP Life Group (ages High School on up)

Child's Name *

Date of Birth: *

YYYY

Age *

Diagnosis *

Mother's Name *

Phone *

Full Address (Street, City and Zip Code) *

Does the mother live at home? *

Yes

Email address *

Alternate phone

Father's Name *

Phone *

Full Addresss - if different than mother's address (Street, City and Zip Code)

Does the father live at home? *

Yes

Email Address *

Alternate phone

Siblings - Names and Ages

My child loves to... *

Enjoys music? *

Yes

Enjoys arts and crafts? *

Yes

Outside play? *

Yes

Writing? *

Yes

Reading? *

Yes

Allergies/Food Sensitivities *

Yes

If yes, please explain

Are allergies/food sensitivities life threatening? *

Yes

EPI pen? *

Yes

Food/Drinks to avoid

Assistance is needed for eating/drinking? *

Yes

Prone to seizures? *

Yes

Other medical concerns

Toileting needs: *

Independent

With assistance

Wears diapers

Signs, gestures, or words to indicate toileting needs

Medication *

Yes

Type and purpose of medication

Main mode(s) of communication *

Verbal

Visual supports

Sign language

Digital devices

Required

My child is independent with... *

My child needs assistance with... *

My child is uncomfortable with or has sensitivities to... *

Behavior concerns to be aware of...

Trigger-points for frustration/resistance...

Calming tools and aids...

Behaviors that may communicate a specific need (please indicate the need where appropriate)

Classroom situations you wish to be contacted about.

Please describe your child's understanding of and relationship with God. *

Goals for your child at church. *

Ideas for the church to better serve your family.

Additional thoughts or comments.

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