Harvest Kids: Special Needs - Harvest Bible Church

Phone number *

Child's Name: *

Child's Date of Birth: *

Ministry of Interest: *

(check all that apply)

Sunday Services 9:00 AM

Sunday Services 11:15 AM

Kids Club

Kids Camp

Child's primary diagnosis and/or health concerns/meds we should be aware of: *

Class that best fits child's developmental age: *

Communicates using:

Words

Phrases

Sentences

Gestures

Sign Language

Communication Device

Other

Understands 1-2 step directions: *

Toileting Needs: *

How does your child communicate toileting needs? *

Behaviour:

(check all that apply)

Shy

Outgoing

Plays alone

Plays in groups

Responds to correction well

Adapts to new situations with difficulty

Is sometimes destructive

Sometimes threatens others

Sometimes hits/bites, or hurts self/others

Sometimes attempts to run away

Self injurious behaviour

My child responds to separation from his/her parents by: *

My child is best comforted by: *

My child's interests are: *

My child lets someone know what he/she needs by: *

What type of play activities does your child enjoy and/or participate in: *

My child becomes upset when/does not enjoy: *

Additional Information:

Please include any special instructions for the care of your child.

Consent - Please write your full name as a Signature *

I/we, named below, undertake and agree to indemnify and hold harmless Ministry Personnel, HBC, and its Leaders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of HBC, as well as of any emergency medical treatment authorized by the supervising individuals representing HBC. This consent and authorization is effective only when participating in or traveling to events sponsored by HBC.