Forrest Park Church of Christ

Our Forever His Day is for children Ages 3 through 6th Grade with moderate to severe special needs. We are very excited to share this special day with your child.

The event will be held on Saturday, October 20th, 2018 from 9:00 am to 12:00 pm.

We will be in contact with you as we get closer to the day to make sure all your questions are answered.

Thank you for registering your child!

Kate Leverett and Shelley Hazel
ForeverHis@ForrestPark.org

Please Note: All Items Marked with a * are required

Student Name *

First Name Last Name Suffix

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Gender *

Male Female

Date of Birth *

Primary Physician's Name *

First Name Last Name

Physician's Office Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Medical Insurance Company *

Policy Number *

Chronological Age *

Developmental Age *

Current weight *

Diagnosis *

Current Educational Setting and Daytime Activities *

Drug Allergies (Type "none" if there are none.) *

Food or Other Allergies (Type "none" if there are none.) *

Dietary Needs (Check all that apply) *

Can feed self without assistance Has difficulty chewing or swallowing Needs soft food Needs food cut into small pieces Has feeding tube (elaborate below)

Dietary: Any other special instructions *

Toilet & Hygiene *

Independent Needs supervision Wears diaper or Pull-up Hygiene assistance needed (wiping, washing hands) Physical assistance needed to transfer to toilet Has an ostomy (elaborate below

Toilet & Hygiene: Any other special instructions

Mobility *

Independent Power Chair Wheelchair Stroller Walker Crutches Service dog Adult hand-held assitance

Mobility: Any other special instructions

Seizures *

Yes (elaborate below) No

Seizures: Special instructions and details (Type "none" if there are none.) *

Other health issues (Type "none" if there are none.) *

List any medications your child is currently taking (Type "none" if there are none.) *

Attitudes and behaviors *

How can we redirect inappropriate behaviors? *

How does your child react to people he/she does not know? *

What type or reward system is used with your child? *

Does your child use verbal or nonverbal communication? *

Verbal Nonverbal

Does your child read? *

Yes No

Does your child write? *

Yes No

Does your child use sign language? *

Yes No

Is your child's speech understandable? *

Yes No

Can your child communicate his/her basic needs? *

Yes No

Any other information we need to effectively communicate with your child? (Type "none" if there are none.) *

Does your child have any sensory processing issues? If so, please explain. (Type "none" if there are none.) *

Does your child have any physical limitations? If so, please explain. (Type "none" if there are none.) *

What type of physical apparatus/equipment does your child use? (Type "none" if there are none.) *

T-Shirt Size *

Youth Extra Small Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult Extra Large Adult 2X

"You didn't ask, but I want you to know this too... *

Parent/Guardian Name #1 *

First Name Last Name

P/G #1 Relationship to child *

Father Mother Guardian

P/G #1 Home Phone *

- Area Code Phone Number

P/G #1 Cell phone *

- Area Code Phone Number

P/G #1 E-mail *

Parent/Guardian Name #2 *

First Name Last Name

P/G #2 Relationship to child *

Father Mother Guardian Other

P/G #2 Cell phone *

- Area Code Phone Number

P/G #2 E-mail

IMPORTANT! Please read and type your name below to give consent to the following:

I/we have disclosed to Forrest Park Church of Christ all pertinent facts and medical conditions about my child's special needs and accept full responsibility for failure to do so.
If my child shows ANY symptoms of illness within the previous 24 hours, I/we will not leave him/her in the care of Forrest Park Church of Christ. If my child shows ANY symptoms of illness while in the care of Forrest Park Church, I understand I will be called and asked to pick up my child.
I/we give permission to Forrest Park Church of Christ to share this information with the volunteers & staff.
In case of emergency or accident, I or my other listed contact person will be called immediately. If necessary, 911 will be called.
I/we the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend this Forever His event organized by the Forrest Park Church of Christ.
I/we understand that there are inherent risks involved in any ministry or event, and I/we hereby release the Church, its ministers, adults, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.
I/we also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider or if I/we do not carry any health insurance.
Further, I/we affirm that the health insurance information provided above, if applicable, is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above.
I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the Forrest Park Church of Christ staff or its volunteers.

Consents & Medical Release Signature (type your name) *

Photo/Video Release (Type your name) *

Briefly describe how you heard about us

Forever His 2018 Registration

Student Information

Medical Information

Medical Background Information

Nutrition/Dietary Information

Toileting & Hygiene Information

Mobility Information

Health & Safety Information

Communication

Sensory & Physical Information

Additional Information

Family & Emergency Contact Information

Consents and Releases

Photo and Video Release

How Did You Hear About the "Forever His" Ministry?