Child's Name:

Child's Date Of Birth:

Diagnosis, Condition, Illness, Or Needs:

My Child Likes

My Child Dislikes:

My Child Is Motivated By:

Signs My Child Is Upset:

Signs My Child Is In Pain:

Signs My Child Needs To Use The Restroom:

Signs For Other Needs My Child May Have:

Calming Tools And Aids:

Classroom Situations You Wish To Be Contacted About:

Goals For Your Child At Church:

Other Details We Should Know (Allergies, Sensitivities, Triggers, Talents, Gifts, Etc.)

My Child's Toileting Skills: My Child's Toileting Skills: Independent Needs Assistance Uses Diapers/Not Potty-Trained

My Child Communicates In These Ways: My Child Communicates In These Ways: Verbally Non-Verbally Sign Language Communication Device Picture Board Other

Parent/Guardian Name(s):

Relationship To Child:

Phone:

E-Mail:

May We Text You? May We Text You? Yes No