Buddy Life Ministry Registration Form

Your name *

Last name

Email address *

Buddy Life Ministry

Christian Life Fellowship cares for each participant in KidLife. These questions are asked for the benefit of your child, so that we may provide the best experience and safest environment for everyone involved. Our church leaders and ministry volunteers respect your family’s right to privacy. Any information shared in this form is communicated directly to those caring for your child and only on a “need to know” basis.

Child's Name: *

Child's Birthday: *

Male or Female? *

Select…MaleFemale

Address *

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Phone Number *

Phone type

MobileHomeWorkOther

Medical Information

My child has the following special needs, diagnosis, medical condition or learning differences.

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

(Drugs, food, or other)

Does your child have seizures? If yes, what are signs that may trigger it? *

Select…YesNo

If your child has seizures, what type?

What therapies or services is your child currently receiving?

Communication and Behavior

My child's mode of functional communication is: Picture Exchange Communication ( PECS), Sign Language, Spoken Word, Assistive Communication device, etc: *

Select…WordsGesturesSign LanguageCommunication BoardAugmentative Talking DeviceOther

Language(s) spoken at home: *

My child can understand what others say: *

Select…AllMostSome of the time

My child is uncomfortable with or has an aversion to ( examples: sound sensitivity, close proximity, texture aversion, hand over hand assistance, transitions, etc.)

My child likes to play with ( cars, animals, puzzles, bubbles, etc. )

When triggered does your child show frustration or anger?

Select…YesNoOther

A trigger for resistance, frustration, or behavioral problems may emerge for my child when:

What are the behavioral problems that may emerge?

What are some strategies you or your child use to help calm when/ if he/she experiences resistance, frustration, or behavioral problems:

Bathroom Policy

We do not change diapers or assist children in the restroom after 3 years of age. If your child requires assistance in the restroom or has a diapering need we will notify you via text during the service.

What are your childs toilet skills? *

Select…Toilets independently Potty trained, needs assistancePotty TrainedDiapersRequires cauterization Other

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

Indicate special toilet needs/schedule

Other Details

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

My child is best comforted by: *

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

Are there any additional concerns not already addressed? *

Submit

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