Ability Tree First Coast CHILD PROFILE
This online child profile form is for our Ability Tree MVPs (children with special needs). However, if you feel the sibling(s) need a profile completed as well, certainly complete one, but it's not required.

IMPORTANT: Completing this child profile does not secure a spot for any program. You will want to complete the registration form with payment (if applicable) to reserve the spot through Eventbrite.

Also, please complete our ATFC Waivers (https://goo.gl/6i6fPS ) for all children attending any activities/events and return to info@abilitytreefc.org. The waivers need to be opened in Adobe Acrobat because they are in writable pdf format and allow you to sign electronically. If you have any issues with completing these waivers, please notify us through our email.

**One profile & waiver packet per child, please.**

Email address *
Child's First and Last Name: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Child’s maturation/cognitive age: *
Your answer
Primary Disability Diagnosis (and Secondary, if applicable): *
Your answer
Please describe diagnosis (use as much detail as you feel would be beneficial):
Your answer
MEDICAL INFORMATION
Physician's Name & Medical Group: *
Your answer
Physician's Telephone #: *
Your answer
Preferred Hospital: *
Your answer
Insurance Company:
Your answer
Policy #:
Your answer
Policy Holder:
Your answer
Medical Diagnosis:
Your answer
Does your child have seizures? (If yes, provide type, duration, & frequency.) *
Your answer
Are seizures controlled with medications?
Food Allergies (if none, please write N/A): *
Your answer
Other Allergies (if none, please write N/A): *
Your answer
CHILD'S ABILITIES & SKILLS
How does your child communicate? (Please check all that apply) *
Required
Your child can understand what others say: *
What's your child's form of mobility? *
Required
Does your child require assistance eating? (If yes, please explain.) *
Your answer
Does your child have special dietary needs? (If yes, please explain.) *
Your answer
Foods your child really likes: *
Your answer
Foods your child really dislikes: *
Your answer
Does your child have bladder control? (If not, please explain, ie wears pullups/diapers.) *
Your answer
Does your child have bowel control? (If not, please explain, ie wears pullups/diapers.) *
Your answer
Does your child need potty reminders? *
Does your child need assistance during toileting? (If yes, please explain.) *
Your answer
For females: Does your child need assistance during menstruation? (If yes, please explain.)
Your answer
BEHAVIORS
What behaviors pertain to your child? (Check all that apply) *
Required
Circumstances when these behaviors occur (if applicable):
Your answer
What do you typically do to remedy the situation (if applicable)?
Your answer
ACTIVITIES
How would you describe your child’s approach to new situations? *
How is your child best comforted? *
Your answer
How would you transition your child to new activities (i.e. five-minute warning, no warning, etc.)? *
Your answer
What activities does your child like to do (i.e. music, coloring, independent play, etc.)?
Your answer
My child needs encouragement to:
Your answer
Please do not ask my child to:
Your answer
Does your child have any fears? (Check all that apply) *
Required
How do you deal with these fears at home?
Your answer
OTHER THINGS TO KNOW
Child's pet's name (if applicable):
Your answer
Child's favorite toy:
Your answer
Siblings Name(s) & age(s):
Your answer
Any additional information you feel would be important for staff to know about your child:
Your answer
Thank you for taking the time to complete your child's profile.
Each profile is reviewed to make sure we are able to create a setting that takes your child's abilities & needs into consideration for a time of fun! We want to set your child up for success, as well as our staff & volunteers.
Submit
Never submit passwords through Google Forms.
This form was created inside of Ability Tree First Coast. Report Abuse - Terms of Service