Work Entry

Sensory Room Registration

Campus

Child's First Name

Child's Last Name

Parent First Name

Parent Last Name

Emergency Contact

Emergency Phone Number

My child has the following diagnosis, medical condition, or learning difference:

My child has the following allergies and/or food sensitivies:

My child is prone to seizures:

Tell us anything else you want us to know regarding your child's physical needs (hearing, vision, toileting, etc.):

My child can independently:

My child needs assistance with:

My child's main mode of functional communication is:

My child has an aversion to or is triggered by:

When my child is escalated, he/she calms when:

My child is most relaxed in this setting:

My child has the following areas of interest:

Music, songs, singing, instruments

iPads or other forms of technology

Crafts or building

Gross motor games & activities

Fine motor or sensory activities

Books, being read to, or reading

Other

My favorite thing about my child is:

The Church can support our family by:

My preference for my child's time in the church's care is:

The goals I have for my child this year (behavioral, academic, social, spiritual) include:

Submit