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Home
About
Mission & Vision
History
Staff
Board
Child Protective Policy
Parent Testimonials
Respite
Respite Program
Respite Care Application-đŸ’¥MANDATORY-fill out first
Special Needs Child Information Form
Medical Information Form
Sibling Information Form
Friday NITE Friends Medical Release Form
Overflow
Overflow Program
Overflow Application
Overflow Applicant Information Form
Overflow Medical Release Form
Calendar
Donate
DONATE NOW
Volunteer Meals
Christmas Party
Volunteer
Volunteer Information
Volunteer Application
Featured Volunteers
Gallery
Connect
Contact Us
What’s Happening
Parent’s Corner
Lending Closet
Special Needs Child Information Form
If you are human, leave this field blank.
*If you have more than one child with special needs, please fill this form out for each child
Name
Male / Female
Birth Date
Current Date
WHAT IS YOUR CHILD’S DIAGNOSIS? (PLEASE LIST ALL PERTINENT DIAGNOSES)
ALLERGIES
PHYSICAL NEEDS
Vision
Typical
Impaired
Blind
Hearing
Typical
Impaired
Deaf
Hearing Aid
Cochlear Implant
Motor
Head Control
Rolls Over
Sits
Crawls
Cruises
Walks
My child uses
Walker
Crutches
Braces
Wheelchair
COMMUNICATION
Speech
Words
Phrases
Sentences
Babbles
Gestures
Sign Language
Other (describe)
Can understand what others say
All of the time
Most of the time
Some of the time
Recognizes Voices of Family Members
Yes
No
Language spoken at home
TOILETING SKILLS
Toilets independently
Needs help
Potty Trained needs assistance
Currently being potty trained
Uses diapers
Indicate special toileting needs schedule
EATING HABITS
Feeds self
Requires Feeding
Bottle Fed
Special Diet
If your child is difficult to feed, please describe any special assistance or adaptive utensils required for eating
BEHAVIOR: (check all that apply)
Shy
Prefers to play alone
Adapts to new situations with difficulty
Responds to correction with difficulty
Is sometimes destructive
Sometimes hits, bites, spits, or hurts self/others
Sometimes attempts to run away
Sometimes threatens others
Hyperactive and/or ADD
Other
My child responds to separation from his/her parents by
My child is best comforted by
My child lets someone know what he/she wants or needs by
What behaviors might we see at Friday NITE Friends?
How often does this behavior occur?
In what settings is this behavior likely to occur? (home, school, work, with strangers, etc.)
What is the most successful way to deal with this behavior?
Can you suggest a positive reinforcer for the child (items or experiences the child especially enjoys)?
List your child’s favorite activities, games, toys, etc.:
What does your child not enjoy?
Is there anything else you wish to tell us about your child?
Submit
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