Special Needs Intake Form | My Eastside

Special Forces is designed to provide a safe and loving environment for children with social, physical, mental and developmental differences. We offer both an interactive classroom experience as well as a buddy system for our children who would benefit from being mainstreamed. Our desire is for parents to feel comfortable so they can experience our weekend services.

Please do NOT fill this form out unless your child has any special needs, different abilities, or health concerns.

PARENT INFORMATION

First Name

Last Name

Address

Mobile phone

Child's Name

Child's Birthdate

Child's gender

Which campus will you be attending?

What service will you most likely attend?

Emergency Contact Name

Emergency Contact Phone #

Alternate Emergency Contact Name

Alternate Emergency Contact Phone #

MEDICAL INFORMATION

Dietary restrictions if any (ie, GFCF, no dairy, etc.)

Please be as open as possible. Knowing we will not turn your child away nor discriminate based on what is listed. Describe Disability Diagnosis, Special Needs and/or Medical Concerns.

Classroom/Playground behaviors to be expected (both positive and negative):

What is your child's primary form of communication? (vocal, non-verbal, partial verbal)

Is vision okay?

If no, please explain:

Is hearing okay?

If no, please explain:

Any restrictions from physical activity?

Please choose bathroom needs:

DISABILITY INFORMATION

Please describe any triggers and/or sensitivities (ie, certain words, behaviors, environmental conditions, touch, loud music, lots of people, etc.)

Please describe any other information including cool down and safety measures helpful for us to know about your child.

DISCIPLINES/CONSEQUENCES

Eastside is committed to using discipline in a loving manner. Our purpose is to shape positive behavior in the participants by providing gentle but firm correction that is appropriate for the individual. Corporal punishment is prohibited by Eastside. Only the following methods are deemed acceptable: Prevention: redirecting a participant for an undesired behavior to a desired behavior. Verbal Reminder: is a reminder that behavior is not appropriate and is redirected. Verbal Reprimand: told “No” in a firm but loving tone. Positive verbal reinforcement is given and is used to encourage and redefine acceptable behavior. Retraining: the participant is led through the steps of performing appropriate behavior. Cool Out Period: if a participants behavior reaches a point of significant disturbance the child may be given a “cool out period” in order to calm themselves. Restraining: in the event a participant becomes physically aggressive to the extent that injury is likely to occur to self or others, temporary physical restraining may be applied. Only staff certified in proper restraints would be involved.

I understand these discipline/consequences can be provided by Eastside Christian Church Special Forces Ministry staff and volunteers. A "yes" is your signature that you've read and agree.

PHOTOGRAPHY RELEASE

I consent to Eastside Christian Church photographing the above named person, without limitations, to use pictures with any work of Eastside Christian Church Special Forces Ministry and hereby release Eastside Church from any claims whatsoever which may arise with regard thereto.

A "yes" is your signature that you've read and agree.

BEHAVIOR PLAN

Does your child have a behavior plan? (If yes, please answer the questions below)

ANTECEDENTS OF BEHAVIORS

What happens before behaviors occur, if anything?

BEHAVIORS

What are the different behaviors that your child can display?

CONSEQUENCES OF BEHAVIORS

What happens after behaviors occur, if anything?

CURRENT BEHAVIOR STRATEGIES/SUPPORTS

Please list any strategies that your child is using. For example, first/then, positive reinforcement, negative reinforcement, picture schedules, etc.

CHILD'S LIKES (REINFORCERS) AND DISLIKES

Submit