Special Needs Ministry: Student Registration
Today's date: *
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Student Name: *
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Parent/Guardian Name(s): *
Your answer
Phone: *
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Address: *
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Back-up Emergency Contact: *
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Emergency Contact Phone: *
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Siblings Names & Ages *
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School Student Attends: *
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Grade: *
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Student's diagnosis and health concerns we should be aware of: *
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Reading level and writing skills: *
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Communication skills: *
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How does your child learn best? *
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Allergies? *
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Seizures? If yes, what should be done if your child has a seizure during this time? *
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Medication? *
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Can student go outside for activities? *
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Is assistance needed for eating or drinking? *
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Is assistance needed for using the restroom? *
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Food/Drinks we should NOT give your child: *
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Any specific fears? *
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Any specific behaviors? *
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Any disruptive behaviors? If so, what works best to diffuse the situation? *
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What strategies have or have not worked well with your child in school? *
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Suggestions for making your child more comfortable and this experience more successful: *
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