Special Needs Questionnaire Posted on November 15, 2023January 24, 2024 by Josh Burdick Special Needs Child QUESTIONNAIRE let us make your child’s experience the best it can be. Child's Name Parent's Name Parent's Email Parent's Phone Emergency Contact Emergency Contact Phone My child’s diagnosis/medical condition/learning difference My child's learning style auditory visual tactile read/write My child's main mode of communication verbal sign language speech device other (please specify) My child likes My child dislikes/is uncomfortable when My child is pottytrained yes no If no, would you prefer our volunteers to change your child’s diaper, or would you rather us contact you to do so? yes no My child is calmed by If your child is calmed by touch, do you give your permission for our volunteers to do so? yes no Does your child have any allergies? yes no If yes, what are his/her specific allergies? My child may have the snacks provided in class yes no (my child will bring his own snacks to class) Areas my child receives therapy Areas my child needs assistance Additional comments/information about my child I am planning to attend: Sunday Bible Study Groups — 9 A.M. Sunday Morning Worship — 10:15 A.M. Sunday Evening Worship — 6 P.M. Wednesday Evening — 7 P.M. When do you plan to visit? Send
