Wonderfully Made Application

Wonderfully Made Ministry Application

We exist to connect individuals with special needs and their families to Jesus Christ
Individual With Special Needs
Name

First NameLast Name
E-mail
example@example.com
Phone Number

Area CodePhone Number
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Age
Parent/Guardian/Caregiver Info
Name

First NameLast Name
E-mail
example@example.com
Cell Phone

Area CodePhone Number
Individual with special needs has the following diagnosis or medical condition:
Individual with special needs needs 1:1 assistance?

YesNo
Current medications:
Seizures:

NoneControlledUncontrolled
Does individual with special needs have a seizure plan?

YesNo
If yes, please give description of plan or include plan with application:
Allergies/Food to avoid/Restrictions:
Foods individual with special needs enjoys:
Please Check all that apply

IndependentEats by G-tubeFeeds self with promptsUses special utensils/cupRequires supervisions/physical assistance while eatingOther
Language Skills:

VerbalNonverbalLimited verbalSign language
Toilet/Hygiene Needs:

Uses toilet independentlyUses toilet with supervisionNeeds transfer assistanceOn a scheduleDiapers/pull ups
Special transfer, schedule, or changing instructions
What special care needs should we be aware of (examples: auditory, visual,tactile)?
Individual with special needs really enjoys:
Individual with special needs DOES NOT enjoy:
Does individual with special needs have any of the following behavioral tendencies: temper tantrums, running away, yelling, biting, hitting, pushing, aversion to touch, separation anxiety, difficulty following directions, doesn’t like being in large groups, other, etc. Please describe:
What triggers these behaviors?
What warning signs are there for these behaviors?
Do you have a behavior plan in place? (Explain)
Best way to encourage them and to get and keep attention:
Any other information that will help us understand and work with individual with special needs:
What other programs/activities/events/support can the Wonderfully Made Ministry offer that will help individual with special needs?
Do you have a medical plan of care for emergencies in place? If, so please submit to Rachel Frazure at rachelfrazure@mychristchurch.com
Any medical or special precautions?

SeizuresG-TubeTrach TubePositioningRespiratory
Toilet/Hygiene Needs

Uses toilet independentlyUses toilet with supervisionNeeds transfer assistanceOn a scheduleDiapers/pull ups
Any behaviors we should be aware of (wandering, tantrums, aggressive behaviors)?
Do you have a behavior plan in place? Please Explain
Best way to encourage them and to get and keep attention:
Any other information that will help us understand and work with individual with special needs:
What other programs/activities/events/support can the Wonderfully Made Ministry offer that will help individual with special needs?
Photograph/Media Release Consent
Should be Empty:

Wonderfully Made Ministry Application

Individual With Special Needs

Parent/Guardian/Caregiver Info