Special Needs Buddy Ministry

Child Intake Form

Please fill out the form below to request a buddy for your child.
Please note: Buddies will only be available at the Littleton Campus Sunday 9:15 + 11 AM services.

"*" indicates required fields

Child Information

Name*
MM slash DD slash YYYY
Gender*
Child resides with:*

Caregiver Information

Relation to child*
Address*

Medical and Insurance Information

In case of an emergency, the following information is helpful:
Do you have a medical plan of care for emergency procedures?*
Max. file size: 50 MB.
What is the degree of severity of the disability?*

Dietary and Feeding Skills

Do we have permission to feed your child during service?*
What method of liquid intake does your child use?*
What method of eating does your child use?*

Toilet/Hygiene Skills

Please check all that apply (provide detail in the box below):*
Should we ask your child if they need to use the toilet when in our program?*

Communication Skills

My child is:*
Please check all that apply:*
Will your child use other behavior(s) to communicate a want/need (cry, hit, run away)?*
Your child can understand what others say:*

Motor Skills

Child’s fine motor skill level: (i.e., handling small items)*
Child’s gross motor skill level: (i.e., larger movements)*

Behavioral Skills

Behavior Concerns
Please check all that apply (provide detail below):*

Behavioral Skills

Behavior modification plans

Authorization to Provide Medical Services Release

Parent/Guardian Consent
Printed Name of Parent/Guardian
MM slash DD slash YYYY

If you have any questions about this form, please contact Whitney Sarnowski at [email protected]. Please note that photography and video recording may take place while you’re at Mission Hills. Your presence on the campus signifies your consent Mission Hills Church using your image. Thanks for your cooperation.