Form Entry

Complete the form below and someone from our team will connect with you soon if we require any additional information.

Child & Family Information

Child's Full Name

Child's Perferred Name/Nickname

Child's Date of Birth

Parent/Guardian 1 Name

Parent/Guardian 2 Name

Phone Number

Emergency Contact [Other than parent/guardian]

Name

Phone Number

Relationship to Child

Medical & Safety Information

Diagnosis

Medical Concerns

Allergies

Medications

Seizure history or other emergencies we need to be aware of?

Communication & Sensory

How does your child communicate?

Verbal Sign Language AAC Device Gestures Other

How does your child best express needs/wants?

Sensory sensitivities (examples: noise, tough, lights, smell):

What calms your child when they are upset?

Are there any known triggers or fears?

Behaviors & Learning

What behavioral concerns or supports are needed?

Can your child participate in a group setting?

How does your child interact with peers?

Learning strengths (visual, hands-on, routine-based):

Areas needing extra support?

Toileting & Mobility

Is your child toilet trained?

Mobility or equipment needed (e.g., wheelchair, walker):

Church Participation

Has your child attended church programming before?

Preferred class age group:

Would a one-on-one buddy be helpful?

Are you comfortable with your child attending without you present?

Is there anything else you'd like us to know about your child?

Do you allow CMC to use photos/videos of the individuals attending our Respite for digital and print platforms of CMC?

Parent/Guardian Agreement

By typing your name in the space below you are agreeing with the following statement: I understand that this information helps Chestnut Mountain Church provide a safer and more supportive ministry environment. I agree to share relevant information for the care of my child while in the CMC Kids Ministry.

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CMC Special Needs Intake Form