EmailMe Form - Autism Ministry Student Profile

STATEMENT OF CONFIDENTIALITY

All information gathered in this profile will be used by the ministry leaders and partners to accurately assess the needs of your child/children and will be kept strictly confidential.

Student's Name *

First Last

Date of Birth *

Grade Level *

Parent/Guardian's Name *

First Last

Primary Phone# *

### - ### - ####

Additional Parent/Guardian's Name

First Last

Primary Phone#

### - ### - ####

Primary Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Student's Diagnosis (if applicable)

Please list allergies below. (if applicable)

Please list preferred snacks below.

Can your child toilet independently? *

Yes

No

If you answered 'yes', if they are non-verbal, how will they communicate they need to go?

Please select the activities below that your child would enjoy participating in: *

Please check all that apply:

Please list any additional information regarding the checked areas above if applicable.

CONSENT

By submitting this form, you agree to be contacted by a representative of Word of Restoration International Church. We respect your privacy. Your information will be used for ministry purposes ONLY.

Parent/Guardian's Signature *

Clear