New Wonderfully Made Family - Heartland Church

Your name *

Email address *

Relationship to child: *

Child (first & last name / age) *

Preferred service time: *

8AM

9:30AM

11AM

Tell us more about your child

My child’s strengths & interests are: *

My child’s main mode of functional communication (check all that apply) is:

Speech (Words)

Speech (Sentences)

Babbles

Sign Language

Gestures & Body Language

Picture Exchange Communication System (PECS)

Communication Board / Device

Voice-Output Device

Other

My child can understand what others are saying (check one):

All of the time

Most of the time

Some of the time

Recognizes voice of family members

My child has the following sensory sensitivities:

(e.g., to light, sound, touch, or smells)

My child uses the following sensory tools:

(e.g., fidget toys, noise-canceling headphones)

Are there any triggers that might cause your child distress or anxiety? *

- If my child experiences a meltdown, these are the calming strategies that have been effective:

Specific strategies and/or techniques that help my child thrive:

(e.g., calming techniques, reward systems)

Health & Medical Needs

My child has the following confirmed diagnosis(es) and/or medical condition(s):

(e.g.,autism, ADD, asthma, diabetes, heart condition, etc.

My child has the following allergies? Please specify. (no food is given or permitted in Heartland Kids classrooms):

My child’s allergies can be life threatening and require the use of an EpiPen, etc.

Yes

Other

Additional allergy information including allergy signs or symptoms:

If prescribed an EpiPen or other injectable for allergies, will they have it with them at church?

My child is prone to seizures:

Yes

If yes, complete seizure action plan:

Are there specific steps you want us to follow in case of a medical emergency. If yes, please list:

Mobility & Physical Needs

Does your child have any mobility challenges (e.g., difficulty walking, using a wheelchair, walker, or crutches)? *

Yes

If yes, please list along with additional info:

Is your child able to independently use the restroom, or do they require assistance? *

Please list if they toilet independently, are potty trained but needs parent called for assistance, wears diapers/pull ups, any other additional info.

Help us ensure the best experience for your child while at Heartland Kids!

The spiritual goals I have for my child are: *

My child does best in settings (check one): *

Alone

With a few children

Among many children

Other

The things that work well for my child are:

The things that won’t work well for my child:

I know my child needs a break when:

My child would... *

Enjoy large group worship experience

NOT enjoy large group worship experience

Your team may experience the following with my child (check all that apply):

Difficulty sitting in groups

Short attention span

Trouble with sensory experiences

Temper tantrums

Tics

Separation Anxiety

Aggressive Behavior

Shyness

Tendency to be possessive

Tendency to run / leave the room without permission

Difficulty with social settings

Challenges with following directions

Difficulty interacting with peers

Additional Information or Explanation about the above?

My child would do best with a 1:1 buddy in the classroom

My child would do best with experiencing programming in the Wonderfully Made room

My child would do best on their own, with occasional check-ins

Any information or random notes you would like to share that was not covered above?