Metro Community Church - Create Your Child's Plan of Care

Child information:

First Name

Last Name

Birthday

Age

Gender

What do you love the most about your child?

Special needs diagnosis:

Does your individual have seizures? If so, what type of seizure?

Provide a seizure protocol if applicable:

Allergies:

Does your individual use an Epi-Pen?

Yes

No

Things your child likes?

Things your child dislikes?

Tools and techniques you use at home to redirect and help with behaviors?

What is one goal you want your child to strive to achieve?

Any additional information you'd like to share?

Communication (check all that apply):

Verbal

Device

Sign language

Other:

Mobility (check all that apply):

Walks independently

Support when walking

Wheelchair

Other:

Bathroom (check all that apply):

Independent

Support in the bathroom

Uses diapers/pull ups

Other:

I give Metro Community Church permission to use my child's picture in social media, presentations, media releases, and newsletters to promote the Metro Special needs ministry at Metro Community Church.

Yes

No

Emergency contact information:

First Name

Last Name

Phone Number

First Name

Last Name

Phone Number

CREATE YOUR CHILD'S PLAN OF CARE

Child information:

Emergency contact information:

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