Club 139 Childcare Application

Your name *

Email address *

Child Information:

Full Name: *

Birthdate *

Gender *

Father's Full Name: *

Phone number *

E-mail Address: *

Mother's Full Name: *

Phone number *

E-mail Address: *

Emergency Contact: *

Phone number *

Grade *

Medical Information:

Any Diagnosed Disabilities or Medical Conditions: *

Current Medications (If none, type none): *

Allergies (If none, type none): *

Any Required Accommodations or Assistive Devices (If none, type none): *

Behavioral Information:

Behavioral Patterns and Concerns: *

Preferred Coping Methods: *

Strategies for Managing Challenging Behaviors: *

Is your child a flight risk? *

Yes

If yes, please explain.

Additional Accommodations

Preferred Communication Methods with the Church: *

Phone

E-mail

Scheduled Meeting

Are there accommodations or modifications we need to consider for your child? *

Does your child have a written Individualized Education Plan (IEP) or other document that identifies a student’s disability, outlines clear goals and objectives, and explains how the student will be supported? *

If yes, we will ask for a copy of this document in order to best accommodate the needs of your child.

Yes

Do you have additional comments, questions, or concerns for the Calvary Kids program? *

Yes

If yes, please explain.