Kids Empowered Intake Form - Linked UP Church

Mobile Phone Number *

Second Parent/Guardian's Name *

Second Parent/Guardian's Mobile Number *

Second Parent/Guardian's Email Address *

Click here if the Second Parent/Guardian is a Caretaker

Is this a new family or an update to an existing family? *

New Family

Existing Family

Child's Information

Child's Name *

Child's Birthdate *

Sex *

Emergency Contact Information

Emergency Contact Name *

Emergency Contact Mobile Number *

Emergency Contact Relationship to the child *

Medical And Functional History

Child's Primary Diagnosis/Disability *

Seizures *

Does the child experience respiratory problems? *

Any other Medical Concerns?

Would you like your child to participate in our buddy program and have a 1 on 1 buddy? *

Speech and Cognition

This child communicates in the following ways: *

Non-verbal but vocalizes

Says words

Talks in sentences but may be hard to understand.

Talks in sentences and is easy to understand.

Uses a communication board

Uses a computer-assisted device

Hearing Needs *

None

Uses a hearing aid

Uses sign language

Cochlear implant

Following Directions *

Is unable to follow directions

Follows simple one-step directions

Follows two-step directions

Has no difficulty following directions

Other

Sensory Needs *

Likes Noise

Sound Sensitive

Other

Mobility *

Walks independently

Uses a wheelchair

Uses Braces

Other

Food Allergies *

Activities of Daily Living Toileting *

Independant

Wears diapers/pull-ups

Requires assistance

Social/behavioral Tendencies *

Temper tantrums

Running away

Yelling

Biting

Aggression

Hitting

Refuses to follow directions

Pushing

Aversion to touch

Other

Please explain your child's social/behavioral struggles or what rewards work to reinforce positive behavior? *

We should contact you if:

Please provide any other information you feel is pertinent:

Waiver

Photo Release Waiver *

I agree to allow photography/videography to be used by Linked Up church for any publicity and/or promotional and/or educational purpose including leaflets, flyers, televisions, newspaper, magazines, advertisements, audio visuals, social media, etc

I accept to the following: *

All activities involve some risk for accident or injury. Linked Up Church does not provide insurance, nor does it assume responsibility for such accidents or injuries. Participation in this program, activity, or facility and the use of its equipment is at the participant’s own risk. I understand and accept these risks. If my child demonstrates continued unwillingness to cooperate or inappropriate behaviors, I understand that I may be paged out of service and/or a meeting may be set up to discuss the behavior. I understand my child may not be able to continue in the program if inappropriate behaviors cannot be corrected.