All-Access Questionnaire

Special Needs Questionnaire

For families of kids, students and young adults with special needs. Please fill out the information below to help us better understand and care for your special child.
Which Church at The Mill campus do you attend?*
Child's Name*

First NameLast Name
Child's Birthday*

MonthDayYear
Date
Child's School*
If not in school, enter N/A.
Grade
Gender*
Guardian's Name*

First NameLast Name
Guardian's Cell Phone Number*
Guardian's Name

First NameLast Name
Guardian's Cell Phone Number
Medical Conditions, Special Needs and/or Diagnosis*
Medications: Please note that we do not administer medications. However, please explain any medications you will have on hand in case of an emergency.
CARE NEEDS
Please select any areas that apply to your child:*

Vision ImpairmentHearing ImpairmentMotor DelayMobility ImpairmentFeeding ChallengesSpeech Delay/ImpairmentSensory ProcessingMedically ComplicatedEmotional/Behavioral ChallengesOther (please explain below)
VISION IMPAIRMENT
Vision Impairment
Please explain your child's vision impairment and how we can best serve him/her.
HEARING IMPAIRMENT
Hearing Impairment
Please explain your child's hearing impairment and how we can best serve him/her.
MOTOR DELAY
Motor Delay: Please select the latest motor milestone your child has reached.
Please explain your child's motor delay and how we can best serve him/her.
MOBILITY IMPAIRMENT
Mobility: Please select which assistive device your child will use while at church.
Please explain your child's mobility impairment and how we can best serve him/her.
FEEDING CHALLENGES
How does your child eat?

Bottle fedFeeds self with handsRequires sippy cupFeeds self with fork/spoonRequires a straw to drinkFull assistance requiredDrinks from cup independentlyNPO
Allergies or dietary restrictions
Please describe any special assistance or adaptive utensils required for eating.
SPEECH DELAY/IMPAIRMENT
Speech Delay/Impairment: Please select all that apply to your child.

NonverbalBabblesUses gestures to communicateUses words to communicateUses phrases to communicateUses sentences to communicateUses a communication deviceApraxiaPhonological disorderArticulation disorder
My child can understand what others say:

All the timeMost of the timeSome of the timeRecognizes voices of family members
Please explain your child's speech delay/impairment and how we can best serve him/her.
SENSORY PROCESSING
Sensory Processing: Please select all that apply.

Is overwhelmed by loud noisesIs overwhelmed by large group settingsPrefers headphonesEnjoys swinging.Enjoys jumping.Enjoys sensory bins.
Please describe any your child's sensory processing needs and how we can best serve him/her.
MEDICALLY COMPLICATED
Please describe your child's medical needs.
TOILETING SKILLS
Toileting*
Indicate special toileting instructions.
BEHAVIOR
Check all that apply.

ShyOutgoingSometimes threatens othersIs sometimes destructivePlays alonePlays in groupsAdapts to new situations wellAdapts to new situations with difficultySometimes hits, bites, or hurts othersSometimes hits, bites, or hurts selfSometimes attempts to run away
What type of activities does your child enjoy and/or participate in?*
My child lets someone know what he/she wants or needs by:*
My child becomes upset when/or does not enjoy:*
My child is best comforted by:*
Any additional concerns not already addressed:
PERMISSION/AUTHORIZATION AGREEMENT

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND YES OR NO INDICATING THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO THE POLICIES.
I understand that it is my responsibility to notify the All-Access staff of my child's attendance to ensure that appropriate assistance can be provided.*

YesNo
I have fully disclosed to Church at The Mill all pertinent facts about my child's special needs and accept full responsibility for missing information.*

YesNo
I remain on campus while my child is in the care of the All-Access Ministry*

YesNo
I have read the above permission/authorization statements and agree to the terms designated in each:*

Clear
Date

YearMonthDay
Date
Should be Empty:

Special Needs Questionnaire

CARE NEEDS

VISION IMPAIRMENT

HEARING IMPAIRMENT

MOTOR DELAY

MOBILITY IMPAIRMENT

FEEDING CHALLENGES

SPEECH DELAY/IMPAIRMENT

SENSORY PROCESSING

MEDICALLY COMPLICATED

TOILETING SKILLS

BEHAVIOR

PERMISSION/AUTHORIZATION AGREEMENT