Tandem - Get to Know Me Form

If you are new to our Tandem Ministry, please fill out this form. We would love to get to know your child as they start attending.

Your name *

Last name

Email address *

Address *

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Phone number *

Phone type

Gender *

Birthdate *

Grade *

What is Your Child's Primary Disability? *

Do They Have a Secondary Disability?

What Age Mentally Is Your Child? *

Is Your Child Prone to Seizures, epilepsy, etc. That We Should Be Aware of? * *

Are they prone to seizures, epilepsy, etc that we should be aware of? *

If so, what should we do in those situations? What are good protocols to follow in those situations? Do they have an alert system?

What Are Some of Your Child's Most Favorite Interests?* *

What are Some Sensory Items Your Child Enjoyes?* *

What Are Things Your Child Dislikes? *

What Sets Your Child off Into Becoming Agitated, Aggressive, Physical, Scream, etc?

Does Your Child Accept/Like Physical Touch? *

For example, rubbing back when agitated, offered hand for guidance, etc.?

Does Your Child Have Any Food Allergies? *

Any Dietary Restrictions?

What Is Your Child's Form of Communication? *

Expressive (Verbal)

ASL

Gestural

IPad / PECS

Other

Personal Hygiene For Your Child? *

Fully Independent

Needs Some Assistance

Currently Potty Training

Diapers / Fully Dependent

Needs to be asked occasionally

Mobility Capabilities *

Walks Independently

Walks with Assistance (holds hand)

Wheelchair User

Other

Is There Anything Else You Would Like Us To Know as We Care for Your Child?

The Hills Church
welcomehome@hillsonline.org
559-297-2600

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