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Special Needs & Disability Ministry Participant Info
Error
Work Entry
Which campus do you plan to attend?
Fellowship Rogers
Fellowship Fayetteville
Fellowship Bentonville
Fellowship Mosaic
Participant's Name
Birthdate
Jan
Feb
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Apr
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1
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31
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2015
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2012
2011
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2009
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1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Type 'none' if not in school
School Name
Grade
Early Childhood
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
College Student
No longer in School
Address
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Parent 1 Name
Parent 1 Cell
Parent 1 Email
Parent 2 Name
Parent 2 Cell
Parent 2 Email
Please list the participant's siblings and their birthdates
Family Information
Participant's Diagnosis, Medical Condition, or Learning Difference
Is the participant an elopement risk?
No
Yes
Medications
Allergies (Food or Other)
Does the participant have a feeding tube?
No
Yes
Is the participant allowed to have snacks?
No
Yes
Are there any food restrictions?
Emergency Contact (Name, number, and Relation)
Participant Likes
Participant Dislikes
Participant Needs Assistance With (i.e. toileting, food, etc.)
Participant's Main Mode of Functional Communication
Participant Seems Most Relaxed in Settings...
What helps participant to calm down if they are upset?
Are there circumstances where a parent would want to be contacted and/or called out of service?
Anything else that would help us better serve you and your child?
I give Fellowship Special Needs & Disability Ministry (and all Fellowship staff who manage social media accounts) permission to post pictures of this participant on Fellowship social media accounts (website, Facebook, Instagram, etc.)
No
Yes
Submit