Kids Care Questionnaire

For Families of Kids with Disabilities and Additional Needs

Child Info

First Name

Last Name

Date of Birth

/ /

Age/Grade

Gender

M F

Campus attending

Plan to attend

Adult Info

Parent/Guardian#1

First Name

Last Name

Relationship to Child

Phone Number

Phone Type

Cell Home

Address

Parent/Guardian#2

First Name

Last Name

Relationship to Child

Phone Number

Phone Type

None Cell Home

Address

Care Info

Child's primary health concerns/diagnosis:

Medications we should be aware of:

Type of assistance that you think would be the most beneficial for your child:

Side-by-side (One-on-one volunteer that assists in ways unique to your child's needs) Room Assistant (Oversees multiple kids in a room who could benefit from basic help with attention, redirection, sensory or social needs) Personal Care Assistant (Assistance provided by parent/guardian. A background check is required) No extra assistance is required. I just want you to be aware

Vision:

Hearing:

Motor:

Uses:

Speech:

Can understand what others say:

Feeds self by using:

Drinks from a cup:

Allergies and/or Special Diet:

Is your child allowed to eat snacks provided by the program?

Toileting Skills:

My child's strengths are:

My child responds to separation from his/her parent(s)/guardian(s) by:

My child is best comforted/calmed by:

My child lets someone know what he/she wants or needs by:

What type of play activities does your child enjoy and/or participate in?

Do you have any additional concerns not already addressed?

Submit

Kids Care Questionnaire

Work Entry

Kids Care Questionnaire

For Families of Kids with Disabilities and Additional Needs

Child Info

Adult Info

Parent/Guardian#1

Parent/Guardian#2

Care Info