Next Gen Care Questionnaire

Home
Connect
Kids Ministry
Next Gen Care Questionnaire

Error

Work Entry

Added: 3/25/2025

Kids and Student Care Questionnaire

For Families of Kids or Students with Disabilities and Additional Needs

Kid/Student Info

First Name

First Name is required.

Last Name

Last Name is required.

Date of Birth

/ / Date of Birth cannot be a future date.

Age Range

Birth-Grade 5 Grade 6-12

Age Range is required.

Gender

M F

Gender is required.

Campus attending

Campus attending is required.

Plan to attend

Plan to attend is required.

Adult Info

Parent/Guardian#1

First Name

First Name is required.

Last Name

Last Name is required.

Relationship to Child

Relationship to Child is required.

Email address is not valid

Email is required.

Phone Number

Phone Number is required.

Phone Type

Cell Home

Phone Type is required.

Address

Parent/Guardian#2

First Name

Last Name

Relationship to Child

Email address is not valid

Phone Number

Phone Type

None Cell Home

Care Info

Child's primary health concerns/diagnosis:

Child's primary health concerns/diagnosis: is required.

Medications we should be aware of:

Allergies and/or Special Diet:

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

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

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

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

Behavior:

Shy Outgoing Likes to be alone Likes to be in groups Adapts to new situations well Adapts to new situations with difficulty Responds to correction well Responds to correction with difficulty Has difficulty sitting in a group Has difficulty attending Sometimes threatens others Sometimes hits, bites, or hurts self/others Is somewhat destructive Hyperactive and/or ADD Sometimes attempts to run away Has difficulty with transitions Has unpredictable vocalizations At times exhibits vocalizations or verbal outburstsBehavior: is required.

My child's strengths are:

My child's strengths are: is required.

What else would you like us to know about your child?

Submit

651.429.9227
7015 20th Ave S, Centerville, MN 55038