Wonderfully Made Ministry Application

Wonderfully Made Ministry Application

A ministry to individuals with special needs and their families
Individual With Special Needs
Name

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

- Area Code Phone Number
Gender

Male Female

Address

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

Date of Birth

- Month - Day Year
Date
Age
Parent/Guardian/Caregiver Info
Name

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

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

Yes No
Current medications:
Seizures:

None Controlled Uncontrolled
Does individual with special needs have a seizure plan?

Yes No
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

Independent Eats by G-tube Feeds self with prompts Uses special utensils/cup Requires supervisions/physical assistance while eating
Language Skills:

Verbal Nonverbal Limited verbal Sign language
Toilet/Hygiene Needs:

Uses toilet independently Uses toilet with supervision Needs transfer assistance On a schedule Diapers/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?

Seizures G-Tube Trach Tube Positioning Respiratory
Toilet/Hygiene Needs

Uses toilet independently Uses toilet with supervision Needs transfer assistance On a schedule Diapers/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