Ridge Kids | Special Needs Ministry Participant Form

The mission of our Special Needs Ministry at Chestnut Ridge Church is to lead children with special needs into a growing relationship with God and others while supporting them and their families. 

Please type your child's name and age.

Special Needs Ministry

Our Special Needs Ministry is designed with your child in mind. The following questions are asked for the benefit of your child so that we may provide the safest and best environment for your child and our staff. Chestnut Ridge Church leaders and ministry volunteers respect your privacy. Any information shared from this form is communicated directly with those caring for your child and only on a “need to know” basis. Please answer the following questions that apply to your child to help serve your child in the best way.  

My child has the following diagnosis, medical conditions, or learning difference(s):

Please list any behaviors which may indicate a medical emergency (if there are none known, please indicate that below):

Is your child prone to seizures?

My child can do these things independently (toileting, feeding, personal care, transitioning, writing, etc.):

My child needs assistance with (transitions, toileting, feeding, personal care, etc.):

My child has the following food allergies, sensitivities, and/or restrictions:

My child’s main mode of functional communication is (i.e., how does your child express wants and needs?):

My child is uncomfortable with or has an aversion to:

Please list any behaviors we should be aware of (self-injury, biting, hitting, elopement, etc.):

If my child becomes upset, he/she is best calmed by: (Please note: we'll do our best to comfort your child, however, if staff are unable to console your child within a reasonable time, or behavior is escalating, we will contact you):

Child's Interest and Abilities

Please check the options below that best pertain to your child.

Please check all that apply.

Please list any additional interest or activities your child has that you would like to share.

Please provide any additional information you feel would be helpful for our staff who will be caring for your child.

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