Section 1: Help us get to know your child with special needs

Please help us get to know your child with special needs.

Child's Name (required)

Child's Grade (required)

Child's Age (required)

Gender (required)

Child lives with:

Father's/Guardian's name:

Cell #:

Mother's/Guardian's name:

Cell #:

Child's diagnosis, medical condition or learning difference that we should be aware of:

A goal for my child while participating in the Buddy Program is:

Section 2: Care Needs


 Typical Impaired Blind


 Typical Impaired Deaf Hearing Aid


 Head control Rolls over Sits Crawls Walks


 Walker Crutches Braces Wheelchair

Can Communicate with others using:

 Words Phrases Sentences Babbles Gestures Sign Language

Language spoken at home:

Can understand what others say:

 All the time Most of the time Some of the time Recognizes voices of family members


Is your child prone to seizures?

**If "Yes", please fill out and send the "RUMC Seizure Action Plan"

ALLERGIES and/or sensitivities: (Drug, Food, Other):


Feeds self by using:

 spoon fork hands requires feeding bottle fed drinks from cup

Special Diet:

Toileting Skills:

 Toilets independently Diapers Currently being potty trained Potty trained, needs assistance


How does your child indicate a need to use the toilet?

Indicate special toileting needs/schedule:

Behavior: (check all that apply) Shy Outgoing Plays Alone Plays in groups Adapts to new situations well Adapts to new situations with difficulty Responds to correction well Responds to correction with difficulty Is sometimes destructive Sometimes threatens others Sometimes hit, bites, or hurts self/others Sometimes attempts to run away or wander Hyperactive and/or ADD

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

My child processes instruction or information best when (ie: visual, auditory, experiential learner)

A trigger point for a possible "melt down" is:

When my child experiences a "melt down" he/she calms when we:

My child is best comforted by:

My child may be trying to communicate their need for (describe)

when he/she exhibits the following behavior

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

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

My child becomes upset when/or does not enjoy:

Are there any additional concerns not already addressed:

Permission/Authorization Agreement

Please read the following statements carefully and choose "I agree" in the designated space indicating that you have read, understand and agree to the provisions.

I have fully disclosed to Reynoldsburg United Methodist Church all pertinent facts about my child's special needs and accept full responsibility for missing information.

I will supply special food, drinks, snacks, and diapers/wipes for my child as necessary.

I will remain on RUMC campus during the time my child is participating in any ministry event/program, unless it is specifically designated as a "Respite Event".

I understand the nature of the program and do hereby release Reynoldsburg United Methodist Church and its representatives from any liability due to accident or injury incurred by my child.

I authorize Reynoldsburg United Methodist Church to publish photos of my child (without his/her name) on our RUMC website and brochures for promotional purposes only.

I have read and agreed the above/authorization statements and agree to the term designated in each:(please type your name)