Spectrum of Light - Family Information - Revolution Church of McKinney

Your name *

Email address *

Parent / Guardian Name *

First / Last

Parent / Guardian Name

First / Last

Address

Children with Special Needs: *

Name / Gender / Birthdate (list all that apply)

Siblings: *

Name / Gender / Birthdate (list all that apply) If none, please type "none"

Emergency Contact Information

Primary Contact *

Name and Relationship to Child

Phone number *

Secondary Contact *

Name and Relationship to Child

Phone number

Other Contact

Name and Relationship to Child

Phone number

Child's Name / Gender / DOB *

What does your child prefer to be called?

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

Vision: *

Normal

Impaired

Hearing: *

Normal

Impaired

Motor: *

Normal

Impaired

If "Motor" is checked - Child is assisted with:

wheel chair

walker

crutches

none

Other

If "other" is checked:

Please explain:

Communication Methods:

Check all that apply:

verbal

sign language

gestures / vocalizations

communication device

not yet communicating

Other

If sign language / communication device / Other checked above:

Please explain:

Toileting Skills

Wears:

Underwear

Diapers / Pull-ups

Sits on toilet

Yes

Indicates he/she needs to go by:

Needs to be taken to the bathroom every ___________ minutes

Initiation

Needs to be asked if he/she needs to go

Does not initiate

Please list all allergies:

Are any of these allergies life-threatening?

Yes

Please list life-threatening allergies:

I will supply an Epi-Pen:

Yes

My child has had a seizure in the past:

Yes

My child currently has seizures:

Yes

If your child currently has seizures, please answer the following questions:

Average Frequency:

Please indicate how many times per day / week / month / year

If my child has a seizure that lasts more than ______ minutes, please call 9-1-1

My child has a VNS (Vagus Nerve Stimulator)

Yes

Emergency Medication

I will provide emergency medication to give in case of a seizure, provide
instructions for its use, and teach the staff/volunteers how to administer it:

Yes

My child is on a restricted diet:

Yes

My child eats inedible objects (play-doh, crayons, etc.)

Yes

Diet Restrictions:

Please check all that apply:

Tube-fed

Pureed food only

Gluten-free

Food allergies (please list allergies above)

Other

If checked "other" above:

Please explain:

My child dislikes:

Check all that apply:

Loud noises

Crowds

Sharing toys

Being touched

Being told “no”

Transitions

Changes in routine

Waiting

Other

If checked "Other" above:

Please explain:

Behaviors that he/she may display:

Check all that apply:

Crying

Screaming

Running away

Spitting

Hitting

Kicking

Pinching

Biting

Taking off clothes

Flopping on the floor

Other

If checked "Other" above:

Please explain:

The best way to handle these behaviors is to:

Please tell us anything else about your child that might assist us in caring for him/her:

Spectrum of Light - Family Information

Emergency Contact Information

Care Information

Initiation

Allergies

Seizures:

If your child currently has seizures, please answer the following questions:

Feeding

Behavior