Champions Club - First Time Applicant

The person completing this form is the child's ... *

Are you the child's legal guardian? *

Child's First Name *

Child's Last Name *

Birthdate *

Gender *

Grade *

Address *

Child's Diagnosis *

Is the Child *

(If your child uses a communication device, sign language or a PEC system please indicate which one using other and listing which one your child uses.)

Verbal

Non Verbal

Speech Language Delayed

Other

Language/Spoken/Understood *

Which Service(s) do you plan to attend? *

We can accommodate Champions for one Sunday service and Wednesday evening service.

Sunday 9 a.m.

Sunday 11 a.m.

Wednesday 7 p.m.

Mother's / Legal Guardian's First and Last Name

Mother's / Legal Guardian's Cell Phone Number

Father's/ Legal Guardian's First and Last Name

Father's Cell Phone Number

Child Lives With... *

Does your child have siblings? *

Emergency Information

Include a Name/Number different from parent/guardian

First and Last Name *

Phone number *

Relationship *

Health Information

Address

Health Conditions: *

Please select all that apply.

Asthma

Anxiety

Brain Injury

Celiac Disease

Diabetes

Digestive Disorder

Epilepsy

Hearing Impaired

Heart Defect

Vision Impaired

Other

If your child has seizures please tell us what they look like.

Giving detailed instructions on what the Champions Club team needs to do for your child during a seizure.

Toileting Needs *

Please provide any necessary supplies for all toileting needs.

Dietary Restrictions/ Allergies

Can your child eat solid food? *

Feeding Instructions *

Dietary Restrictions *

Food Allergies *

Medicine Allergies *

Other Allergies

Developmental Level

Physical Functioning Level *

Cognitive Functioning Level *

Emotional Functioning Level *

Social Functioning Level *

Education Information

Is your child enrolled in school? *

If yes, what school is your child enrolled?

Grade Level *

Does your child use a chewy? *

Yes

No

Does your child receive Special Education services?

Other information about behavior: *

Please include additional information on behaviors listed above or behaviors not listed. Please included any triggers the Champion may have.

Behavior Information

Problems Behaviors *

Runs Away/ Elopement

Touches others inappropriately (please describe this behavior below in other)

Aggressive to self (please describe this behavior below in other)

Aggressive to others (please describe this behavior below in other)

Screams/yells

Throws objects

Bites

Consequences and Discipline Plan *

Time Out

Loss of items (Toys/games, TV, Computer)

Redirect

Task Completion

Reinforces and Reward System *

Praise

Food

First/ Then Visual Supports

Tangible Reward

Preferred Item

Other information about reinforcements and reward system *

Please list items that your child prefers such as foods, toys and musical choices. Or any ways we can support your child while with us in Champions Club.

What calms your child?

Please provide any additional information that would assist us in caring for your child.

When is child happiest?