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gracespring Bible Church
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gsKIDZ Support Request Form
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gsKIDZ Support Request Form
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Child and Family Information
Child's Name
*
First
Last
Today's Date
*
Child's Birthday
*
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Child's Age
*
Child's Grade
*
First and Last Name of Parent(s)/Guardian(s)
*
Siblings (names and ages)
*
Contact Information
Mom's Phone Number
*
Okay to text?
*
Yes
No
Dad's Phone Number
*
Okay to text?
*
Yes
No
Other contact information (if any):
Health and Medical Support
Diagnosis/Medical Condition/Disability/Learning Difference:
*
Food Sensitivities/Allergies:
*
Special Physical Needs:
*
Toileting Needs:
*
Please provide us any additional information that would allow us to best care for your child:
*
Behavioral Support
Is your child ever aggressive toward adults or other children?
*
Yes
No
If YES, what is the best way to prevent aggression (known triggers) and/or handle it when it occurs?
Does your child ever engage in self-injurious behaviors such as head-banging or wrist-biting?
*
Yes
No
If YES, what is the best way to prevent self-injurious behaviors and/or handle them when they occur?
Does your child ever try to run or escape an environment, such as a classroom?
*
Yes
No
Does your child have specific sensory needs or preferences we should be aware of?
*
If your child becomes upset (angry/sad), what is the best way to calm him/her down?
*
What are some of your child’s favorite activities?
*
Placement/Setting
Which of the following settings would you prefer for your child?
*
Classroom with same-age peers with special supports in place
Specially prepared room with few children and specially trained adults
Placement with peers with a one-on-one support person
Please know that our first priority is safety for your child as well as the others in our care. We may at times need to make decisions in the moment to ensure safety for all involved.
Anything else you would like us know about your child or your family that will help us to serve you best?
*
We have been praying for your family to join us and are looking forward to meeting you. If you have specific questions, please text or call Gwen Wild at 817-564-4564 or email gwenwild@msn.com.
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