Special Needs Intake Form for Children's Ministries

Thank you for entrusting your child with us for VBS 2026! We have a heart for helping special needs families get to enjoy the same experiences that other students have. The information below will help us provide the best possible environment for your child to succeed. Each child who needs assistance will receive a 1-on-1 aide who has special needs experience. If you desire to attend with your child, you can note that below as well. We can't wait to welcome you to a week full of Jesus's love and fun!

Parent Name

This address will receive a confirmation email

Phone

I, the guardian, plan to attend with my child

Yes No

If yes above, do you consent to a background check? It will be sent via email, to ensure the safety of all students Yes No

Address

Child's name

Gender

Male Female

Grade Entering in the Fall

Child's Birthdate

Introduce us!

I'd like you to know this about my child

My child is really good at:

My child is interested in:

Any helpful background information

Any other helpful information

My child has special considerations in the following areas:

Medical Communication Developmental Behavioral Sensory Physical

My child would benefit from having a 1-on-1 aide

Yes, definitely Yes, but not necessary Not needed

Medical Considerations

My child's diagnoses

Allergies or Food Sensitivities

My child's allergies may require the use of an EpiPen (if yes, the EpiPen should be packed and labeled with the child upon arrival)

Yes No

My child is prone to seizures

Yes No

If yes, how does the seizure present? Are there any warning signs or preventions?

Notes

Physical Considerations

My child can do these things independently:

My child needs assistance with:

How can we best assist your child:

My child has assistive devices for:

Communication Considerations

My child's main mode of communication is:

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

Explain any specific ways your child will communicate a particular need

Developmental Considerations

My child currently receives therapies and special instruction in:

My child has an 504/Individualized Education Plan

Yes No

If yes, are there aspects of your child’s 504/IEP that could be beneficial for the church environment:

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

My child can do these things independently:

My child needs assistance with:

Behavioral Considerations

A trigger-point for a potential meltdown is when:

When/if my child experiences a melt-down he/she calms when we:

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

Sensory Considerations

My child ______ enjoy music

does does not is indifferent

My child seems most relaxed in settings

Alone with a small group with many children

My child ______ enjoy a large group worship experience (noisy)

would would not

My child is really picky about:

My child is uncomfortable with or has an aversion to:

Special Needs Intake Form for Children's Ministries

Description

Please Fix the Following