Special Needs Ministry Family Intake Form

Please fill out this form and click submit.

Thank you for allowing us to support your family through our Special Needs Ministry. The information provided will help us create a safe, welcoming, and enriching environment for your loved one.

Primary Caregiver Information

Name

*

Relationship to Participant:

*

Email

*

This address will receive a confirmation email

Phone

*

Address

*

Preferred Method of Contact (select one):

*

Please select all that apply.

Email Phone Text

Participant Information

Name

*

Date of Birth

*

Gender

*

Please select one option.

Male Female Prefer not to say

Diagnosis (if applicable - This helps us better understand how to support your loved one.)

*

Allergies or Medical Concerns:

*

Does your loved one have seizures?

*

Please select all that apply.

Yes No

(If yes, please provide details on triggers, typical duration, and emergency care instructions.)

Does your loved one require mobility assistance?

*

Please select all that apply.

Yes NO

(If yes, please describe any specific equipment or assistance needed.)

*

Communication Preferences

How does your loved one best communicate?

*

Please select all that apply.

Verbally Non-verbally (gestures, pointing, etc.) Using communication devices Other

Other description:

Are there specific words, signs, or tools we should know to help communicate effectively?

*

Behavioral and Sensory Needs

Are there specific triggers or situations that may cause discomfort, anxiety, or meltdowns?

*

What are some strategies or tools that help calm or comfort your loved one?

*

Does your loved one use sensory aids or tools (e.g., headphones, weighted blankets)?

*

Are there any activities or environments your loved one particularly enjoys or dislikes?

*

Participation Details

Would your loved one benefit from a Buddy to assist them during services?

*

Please select all that apply.

Yes No

Is there anything else you’d like us to know to better support your family?

*

Emergency Contact Information

Name

*

Phone

*

Relationship to Participant:

*

Media Release

Do you give Christ’s Church of Yukon permission to take photos/videos of your loved one during activities for internal or promotional use?

*

Please select all that apply.

Yes No

By submitting this form, you acknowledge that the information provided is accurate and will only be used by Christ’s Church of Yukon to create a safe and welcoming environment for your loved one.

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