Heartland Church of Sun Prairie - WM Child Information Form

Wonderfully Made
Child Information Form

Our number one job is to love and serve your child, while teaching them about Jesus and helping them grow spiritually.
We recognize that when a child comes to know Jesus, we can’t simply use a one-size-fits-all approach.
Please complete this form as thoroughly as possible so we know how to serve your child well. Thank you!

GENERAL INFORMATION ABOUT YOUR CHILD

First Name

Last Name

Address 1

Address 2

Country

City

State

Zip/Postal Code

Phone Number

Parent/Caregiver Email

Gender
Male
Female

Age/Grade

TELL US MORE ABOUT YOUR CHILD

Time to BRAG! My child's strengths are:

My child's interests are:

My child's main mode of functional communication is:
Speech (words)
Speech (sentences)
Babbles
Sign Langage
Gestures & Body Language
Picture Exchange Communication System (PECS)
Communication Board / Device
Voice-output Device

Additional Information or Explanation

My child can understand what others are saying:
All the time
Most of the time
Some of the time
Recognizes voice of family members

Additional Information or Explanation

My child best processes instruction or information:
Visually
Auditory
Tactile / Experiential

Additional Information or Explanation

My child's sensory needs can best be described as (check all that apply)
Seeks out sensory experiences
Avoids sensory experiences
Seeks constant stimulation
Poor body awareness
No concerns
Other

Additional Information or Explanation

My child receives the following therapies and/or special instruction:

My child is uncomfortable with or has an aversion to:

If applicable, what may be a trigger-point for a potential meltdown?

If my child experiences a meltdown, these are the calming strategies that have been effective:

PHYSICAL NEEDS

My child uses a wheelchair:

My child can be transported out of his / her wheelchair to participate in activities:

If YES,
I (we) will transport
Wonderfully-Made trained team member can transport

HEALTH & MEDICAL NEEDS

My child has the following confirmed diagnosis(es) and/or medical conditions:

My child has the following food allergies and/or food sensitivities:

If applicable, my child's allergies can be life threatening:
YES
NO

and require use of an EpiPen
YES
NO

Additional information, including allergy signs or symptoms:

My child is prone to seizures:
YES
NO

If YES, we will email you a Medical Action Form

TOILET NEEDS

My child: (check all that apply)
Toilets independently
Wears diapers
Is potty trained but needs some assistance
Needs parent called for assistance

My child indicates a need to use the toilet by:

My child washes hands: (check all that apply)
Independently
With reminders
With assistance

HELP US ENSURE THE BEST EXPERIENCE FOR YOUR CHILD

The spiritual goals I have for my child are:

My child enjoys music:
YES
NO

My child is most relaxed in settings:
Alone
With a few children
Among many children

The things that work well for my child are:

The things that may not work well for my child are:

I know my child needs a break when:

My child would enjoy large group worship experience:
YES
NO
UNSURE

Additional Information or Explanation

My child would do best with a 1-1 buddy while at Heartland

My child would respond best to a:

The most valuable thing your team can do to serve our family is: *

WHO FILLED OUT THIS FORM?

First Name

Last Name

Your relationship to the child:

Submit

Wonderfully Made
Child Information Form

GENERAL INFORMATION ABOUT YOUR CHILD

TELL US MORE ABOUT YOUR CHILD

PHYSICAL NEEDS

HEALTH & MEDICAL NEEDS

If YES, we will email you a Medical Action Form

TOILET NEEDS

HELP US ENSURE THE BEST EXPERIENCE FOR YOUR CHILD

SERVICE TIMES

CONTACT INFO

FOLLOW US

Wonderfully Made Child Information Form

GENERAL INFORMATION ABOUT YOUR CHILD

TELL US MORE ABOUT YOUR CHILD

PHYSICAL NEEDS

HEALTH & MEDICAL NEEDS

If YES, we will email you a Medical Action Form

TOILET NEEDS

HELP US ENSURE THE BEST EXPERIENCE FOR YOUR CHILD

SERVICE TIMES

CONTACT INFO

FOLLOW US

Wonderfully Made
Child Information Form