Accessibility Family Profile Form

Your name *

Email address *

Child's First and Last Name: *

Grade:

*if applicable

Name of School:

*if applicable

Child resides with: *

Mother & Father

Mother

Father

Guardian

Other

Name 1:

If different from above

Relationship to Child: *

Mother

Father

Guardian

Other

Relationship to Child:

Mother

Father

Guardian

Address: Check if different than above.

Alternate Emergency Contact

Area(s) of exceptionality/diagnosis: *

ADD/ADHD

Anxiety disorder

Austism spectrum disorder

Asperger

Cerebral Palsy

Down syndrome

Fetal alcohol syndrome

Fragile X

Hearing impaired

Speech impaired

Seizure impaired

Spinal cord injury

Oppositional defiance

Visual impairment

Other

Please give detailed information on any other conditions/special needs your child has:

Allergies:

(Please list all, along with reactions and treatments):

Sensory Challenges:

Please check all that apply.

Dislikes certain textures

Sensitive to sounds such as loud, sudden noise

Sensitive to visual stimulation

Prefers not to be touched (unless asked or requested by child)

Sensitive to changes in routine or environment (such as a new teacher, new classroom, different teaching structure)

Other

Behavioural Challenges:

Shows aggression such as: kicking, hitting, pinching, pushing, spitting and/or biting when upset

Flight risk (may run out of classroom or away from staff)

Behavioural challenges increase if child has sugar/food colouring (e.g. candy)

Screams/cries when he/she does not want to participate in activities

Is upset when routines or teachers change

Ignores instructions given by others (support staff, parents, caregivers)

Other

When do these behaviours typically occur?

Behaviour Modification Plan:

Please explain in detail the behaviour management plan that is being used at home AND school (if applicable) to help with behaviour.

Does your child attend school/a structured program outside of the home? *

My child responds to separation by:

Please check all that apply.

Screaming or crying for caregiver

Attempts to run away from situation

Can become aggressive or upset

Is not bothered by separation from parents/caregivers

Other

Child's response to other children/adults:

Please check all that apply.

Plays well with others

Is shy in new situations, but generally is quickly engaged in play

Prefers to play alone, but enjoys the company of others in the room

Prefers to play alone and does not enjoy interacting with peers or others

Needs help to respond appropriately to others who want to interact with him/her

Other

Child's preferences:

Please check all that apply.

Enjoys playing in a group

Enjoys playing alone

Enjoys sensory toys (e.g. soft, hard, bumpy, smooth textures)

Enjoys being with his/her peer group

Enjoys music

Enjoys stories

Enjoys physical contact with others (e.g. holding hands with friends during a walk)

Enjoys fine motor activities (e.g. colouring, cutting/pasting, play-doh)

Enjoys gross motor activities (e.g. jumping on the trampoline; going for a walk)

Other

Communication Skills

Forms of Communication Used:

What are the primary ways your child communicates with others?

Speaks clearly

Vocalizations not always understood

Sign language

Picture exchange symbols (PECS)

iPad/computer device

Eye gaze/contact

Other

Assistance needed:

Please check all that apply. Please note that assistance is provided by volunteers who are not professionally trained in the field.

Toileting (e.g. limited assistance required)

Eating/drinking

Interactions with peers

Communication

Direction

Other

Toileting: *

Please check any that apply.

Uses toilet independently

Uses toilet with caregiver/parent's help

Needs to be reminded to go

Wear diapers/pull-ups

Other

Does your child require an accessible washroom? *

My child would be best paired with:

Describe the ideal buddy for your child:

Please note that we only offer our accessibility program during our Sunday service, contingent on volunteers.

Acknowledgement of Consent: *

I hereby give consent for my son/daughter to attend and participate in the RK Accessibility Ministry activities and events. I hereby release Redemption Church Durham and its staff and workers from responsibility and liability for injury and/or illness my child may sustain while participating in ministry related activities.

I understand that it is my responsibility to administer any needed medication for my child and remain accessible while my child participates in ministry activities. *

Contact Information

Child's Siblings

Alternate Emergency Contact

Medical Information

Behavioural Skills

Communication Skills

Assistance Needed

Buddy Support

Please note that we only offer our accessibility program during our Sunday service, contingent on volunteers.