Date(Required) MM slash DD slash YYYY Participating Child's Name:(Required) First Last *For multiple children, a separate form must be completed for each child.Child's DOB:(Required) MM slash DD slash YYYY Parent/Guardian Contact InformationParent(s)/Guardian(s) Name(s):(Required) First Last Parent(s)/Guardian(s) Name(s): First Last Mobile Telephone Number(s):(Required)Mobile Telephone Number(s):Email Address(es)(Required) Email Address(es) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country ALL ABOUT MY CHILDMy child has the following diagnosis, medical condition, or learning difference:(Required)My child's main mode of communication is:(Required)My child's greatest strengths are:(Required)My child has the following area(s) of interest:(Required)My child's favorite activity is:(Required)My child especially enjoys:(Required)Doing/seeing/experiencing this one thing is an important part oof my child's routine:(Required)My child processes instruction or information best when (e.g. visual, auditory, experiential, drama):(Required)My child can do these things independently:(Required)The goals I have for my child include:(Required)Experience CareMy child needs assistance with:(Required)My child is especially picky about:(Required)My child _______ enjoy music.(Required) Does Does Not My child _______ enjoy a large group worship experience.(Required) Would Would Not My child is uncomfortable with or has an aversion or sensitivity to:(Required)A trigger point for resistance, frustration, or behavioral problems may emerge for my child when:(Required)When/if my child experiences a period of frustration, he/she calms when we:(Required)My child may be trying to communicate their need for _____ (describe) when (s)he exhibits the following behavior:(Required)My child seems most relaxed in this setting(Required) Alone With a few children Among many children Please detail any other experience-related information of which you would like us to be aware or consider:Medical CareMy child has the following allergies and/or food sensitivities:(Required) Add RemoveMy child’s allergy can be life threatening(Required) Yes No Requires the use of an EpiPen(Required) Yes No My child is prone to seizures(Required) Yes No Describe what prompts the seizure and how we can prevent/respond:(Required)My child’s behavior may indicate a medical problem requiring immediate attention when:(Required)Please detail any other medical-related information of which you would like us to be aware or consider:
