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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