Special Needs Class Registration

We are so blessed to provide your family with a class designed to serve these amazing kids and their parents. Please complete this form so that we can provide your child with the best possible care while they are with us.

Child's name Child's name First Last
Child's DOB Child's DOB / MM / DD YYYY
Father/Guardian Father/Guardian First Last
Mother/Guardian Mother/Guardian First Last
Father's/Guardian's Email Address
Mother's/Guardian's Email Address
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Father's/Guardian's Cell Phone Father's/Guardian's Cell Phone - ### - ### ####
Mother's/Guardian's Cell Phone Mother's/Guardian's Cell Phone - ### - ### ####
Emergency Contact Emergency Contact First Last
Relationship to the child
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
Does your child have any food allergies

Does your child have any food allergies Yes No Unsure
If child has food allergies or sensitivities, please list them here.
What can you tell us about your child's needs? Please select all that apply

What can you tell us about your child's needs? Please select all that apply Learning disabilities Emotional disorders Intellectual disabilitles Physical disabilities Speech & language disabilities Other - please explain below Other - please explain below
Please share anything else you feel would help us best serve your child's needs, such as any specific diagnoses conditions, or limitations including those related to sensory processing.
Does your child take any medication(s)?

Does your child take any medication(s)? Yes No Unsure
If child takes any medication(s), please list them here.
What is your child's main mode of communication?
If non-speaking, how do they communicate at home?
Does your child use PECS or an AAC device or other means of visual communication, pictures, tablet, etc.)?

Does your child use PECS or an AAC device or other means of visual communication, pictures, tablet, etc.)? Yes No Unsure
What are your child's sensory needs?
What behavior does your child exhibit when they are distressed?
What is calming to your child?
What is adverse to your child?
Are there any incontinence issues?

Are there any incontinence issues? Yes No Unsure
How does your child learn best? (hands on, auditory, visual, etc.)
Is your child comfortable making eye contact?

Is your child comfortable making eye contact? Yes No Unsure
If your child is uncomfortable making eye contact, what is the best way to focus their attention?
What activities does your child enjoy?
What activities does your child not enjoy?
Are there any special toys, etc. that would be helpful for your child?
What are your child's hobbies or special interests?
Are there any special situations or prayer needs for our teachers to know?
Is there anything more that we need to know to love and care for your child while they are with us?
Thank you!

We are truly blessed and humbled that you allow us to partner with you and your family in the love and care of these precious ones. Thank you for sharing these amazing children with us.

Special Needs Class Registration

Special Needs Class Registration

Thank you!