Good Shepherd Kids Family Ministry Profile
Family Profile
Name of child with disability:
(first and last name)
Your answer
Nickname:
Your answer
Birthdate of Child:
MM
/
DD
/
YYYY
Age:
Your answer
Gender
Mother's Name
(first and last)
Your answer
Mother's Cell Phone Number:
Your answer
Mother's Email:
Your answer
Mother's Bithday:
MM
/
DD
/
YYYY
Father's Name:
(first and last)
Your answer
Father's Cell Phone Number:
Your answer
Father's Email:
Your answer
Father's Birthday:
MM
/
DD
/
YYYY
Home Phone Number:
Your answer
Address:
Your answer
Address City, State, and Zip:
Your answer
My child is prone to seizures:
Child's Disability:
Your answer
The disability manifests the following complications:
Your answer
I need the church to understand the following about my child:
Your answer
My child enjoys:
Required
My child fears:
Your answer
My child can let you know what he/she needs:
Required
Some important words my child knows are:
Your answer
When my child is unhappy, he/she may act like this:
Your answer
Here are some things we (parents) do at home when this happens:
Your answer
When my child has trouble sitting still, you can help by:
Your answer
If my child doesn't pay attention when you try to show or tell him/her something, you can:
Your answer
When around new people, my child may:
Required
My child likes to play:
Required
When it comes to toys, my child:
Required
My child can do these things independently:
Your answer
My child needs assistance with:
Your answer
I believe my child with a disability would best be discipled:
Required
I believe my child with a disability would best be discipled:
I believe this type of buddy would fit best with my child:
My child's current spiritual state is:
Your answer
My child is allergic to:
Your answer
My child reacts to to something he/she is allergic to by:
Your answer
If my child is having an allergic reaction, please:
Additional Thoughts:
Your answer
I have more than one child:
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