Kids Intake Form

Welcome! Please complete this form so we can help your child have a successful 1st time visit to MCC kids.

Your name *

Last name

Email address *

Phone number *

Phone type

Child's Name *

Gender *

Birthdate *

Grade *

School *

Please help us learn about your child and how we can best provide for them.

These questions allow us to provide the best experience and safest environment for all of our friends within the ministry. Our church leaders and ministry volunteers will respect your family's right to privacy. Any information shared is communicated directly with those caring for your family member and only on a "need to know" basis.

My child has the following diagnosis, medical condition or learning difference: *

My child has the following allergies and/or food sensitivities:

My child's main mode of functional communication is: (e.g. speech board, sign language, verbal) *

My child processes instruction or information best when: (e.g. visual, auditory, experiential, drama) *

My child currently receives therapies and special instruction in:

My child has an Individualized Education Plan: *

Yes

The goals I have for my child's development this coming year: (include behavioral, social, academic, etc.)

My child has the following area(s) of interest:

My child can do these things independently:

My child needs assistance with:

My child is uncomfortable with or has an aversion to:

A trigger-point for a potential meltdown is when:

Doing/seeing/experiencing this one thing is an important part of my child's routine:

My child

does enjoy music

does not enjoy music

My child seems most relaxed in settings

alone

with a few children

among many children

My child

would enjoy a large group worship experience

would not enjoy a large group worship experience

My child is really picky about:

My child may be trying to communicate their need for ___________ (describe) when he/she exhibits the following behavior:

My child is prone to seizures:

Yes

My child's behavior may indicate a medical problem requiring immediate attention when:

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Medway Community Church
office@medwaycc.org
508.533.7032

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