Phone Number *
Phone type Mobile Home Work Other
What is your relationship to the child? *
Select… Mother Father Other
Household members
SELECT '+Add child'
+ Add adult + Add child What is the Diagnosis of the child you just indicated? *
THIS IS THE DIAGNOSIS OF THE CHILD YOU INPUTTED UNDER 'HOUSEHOLD MEMBERS'
Does your child have any additional health conditions? *
Select… Yes Nothing, other than the diagnosis listed above
What is your preferred service to attend? *
In order to accommodate as many families as we can, every family is assigned to one (1) service a week. Please tell us which service you would like to be assigned to.
Select… Sunday 8:30AM Sunday 11:00AM Sunday 2:00PM (Spanish service) None, we are just visiting
Is your child able to communicate verbally? *
Select… Yes, my child uses sentences when speaking. No, my child does not talk at all. Somewhat, my child is able to use some words and/or sentences.
What language does your child understand? *
Is your child in school? *
Select… Yes No
Child lives with: *
Select… Mom and dad Mom Dad Guardian Group home
Does your child have siblings? *
Select… Yes No
Please list another person, other than you, whom we may contact in case of an emergency: *
This person will be contacted in the event that the ministry can not get in touch with you.
Phone Number *
Phone type Mobile Home Work Other
What is the relationship of this person with the child? *
Select… Mother Father Adult Sibling Aunt/Uncle Grandparent Legal guardian Caregiver Other
Can your child eat solid food? *
Select… Yes No
Please list any dietary restrictions your child has, including any food, medical and other allergies.
Physical activity level of your child: *
Please indicate your best estimate of the level of mobility your child has.
Select… High Medium Low
Cognitive level of your child: *
Please indicate your best estimate of how much you believe your child is able to understand.
Select… High Medium Low
Is your child able to identify and regulate his/her emotions? *
Select… Yes No I don't know
Is your child social and able to relate to others? *
Please tell us what problem behaviors your child is currently displaying *
Consequences and discipline plan. *
Reinforcers and reward systems. *
What calms your child during a tantrums or when he/she is afraid?
Does your child need personal space when upset or does your child need talking down to relax?
Does your child need a diaper change?
Please note any additional information that would help us to provide the best care for your child:
I hereby grant to Lakewood Church, any third party affiliated organizations, its legal representatives and assigns, the absolute right and permission to use my name and likeness and to use and publish photographic pictures, video footage and sound recordings of me during church related events, whether via print, digital, broadcast or in any other media and for any lawful purpose whatsoever, at their discretion. I RELEASE, DISCHARGE, AND AGREE TO HOLD HARMLESS LAKEWOOD FROM ANY LIABILITY FOR ANY USE OF THE PHOTOGRAPHS AND VIDEOS.
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