GIFTED Ministry Information Sheet

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Name

*

Date of Birth

*

Nick Names(s)

*

Parent(s) Name

*

Phone

*

OK to send texts?

*

Please select one option.

Yes No

Do you need a buddy?

*

Please select one option.

Yes No

HELP US GET TO KNOW YOUR CHILD BETTER

Medical Diagnosis

*

I enjoy:

*

Please select all that apply.

Books Videos Cars Building Bikes Music Water Art Walking Helping Sports Technology Other (use space provided below)

I get frustrated when:

*

Please select all that apply.

Loud Noises Bright Lights Darkness Being Touched People in my personal space Talking I'm hungry I'm tired Other (use space provided below)

You can help me calm down by:

*

Please select all that apply.

Food/Drink Quiet Time Talking with someone Hugs Using Technology Music Videos Other (use space provided below)

Dietary Restrictions/Allergies:

*

Please select all that apply.

Milk Nuts Gluten Dyes Bottle Tube Feed Other (use space provided below)

Restroom Needs:

*

Please select all that apply.

Independent Diaper Ok, but needs supervision Other (use space provided below)

Sensory Needs:

*

Communication:

*

Please select all that apply.

Verbal Non-verbal Sign Language Communication device Other (use space provided below)

Other:

*

Please select all that apply.

Seizures Diabetes Other (use space provided below)

Description

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Please Fix the Following

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