Respite Night: Kids with Disabilities

February 12, 5 pm - 8 pm
17111 Klinton Dr Boonville, MO 65233
Ages 6 weeks to 17 years old

Please note: Our volunteers will not administer medications, provide medical care, or change diapers. This is to protect both parties. A background-checked caregiver over the age of 18 or a nurse is welcome to attend with the child to tend to these needs.

Participant First and Last Name

Nickname - let us know if the participant has a preferred nickname.

Grade (if applicable)

Gender

Female Male

Additional Participant Information

Riverside Christian Church cares for each participant in our Accessibility Ministry. These questions are asked for the benefit of the participant/dependent and so that we may provide the best experience and safest environment for everyone involved. Our volunteers respect your family's right to privacy. Any information shared from this form is communicated directly to those caring for the participant and only on a "need to know" basis. Please answer the questions that apply to your child, and that may help our church best care for your child.

Your participant is amazing, wonderful, and all-around-awesome because...

Diagnosis/Special Need (You may include assumed diagnosis or diagnosis you are waiting on testing for)

ADHD Anxiety Autism Cerebral Palsy Developmental Delay Down Syndrome Emotional Disability Fetal Alcohol Syndrome/Fetal Alcohol Spectrum Disorder Foster Care Fragile X Syndrome Hearing Impaired Learning Disability Multiple Sclerosis Muscular Dystrophy Opposition Defiance Disorder Physically Disabled PPD Spectrum Prenatal Substance Exposure PTSD/Trauma Rett Syndrome Seizure Disorder Torettes Syndrome Visually Impared Other

If you checked "other" please explain.

Please list the severity of each diagnosis checked above. (Mild / Moderate / Severe)

Communication Needs - Please check all that apply

Predominantly non-verbal Predominantly verbal Speaks clearly Requires prompts/cues to initiate Vocalizations not always understood Requires prompts to interact Eye contact Gestures - Give examples below Signs - Give examples below Assistive technology (picture boards, books, talkers) Give examples below Other

Other and/or Details (Cont. Communication Needs): If you marked other (or one that examples are requested) above, please describe

My participant understands what we say

All of the time Most of the time Some of the time Other

If you checked "other" please explain.

Mobility Needs- Please check all that apply

Walks Independently Electric scooter Uses cane/crutches Uses walker Uses wheelchair

Dietary/Feeding Needs - Please check all that apply

Eats by mouth independently Eats by mouth with supervision/assistance Eats by mouth with set-up Eats by G-tube Feeds self with prompts Uses special utensils/cup

Please list all food allergies, severity, and action steps

Please list all allergies to medication, severity, and actions steps

Please list any medical or special precautions for managing concerns (such as seizures, G-tube, Trach, Positioning & Respiratory) and explain.

Toilet/Hygiene Needs - Please check all that apply

Uses toilet independently Uses toilet with supervision Needs transfer assistance. Explain below Other

Other and/or Details (Toilet/Hygiene Needs Cont.) - If you marked other (or one that explanation is requested) above, please describe

List signs or gestures that may indicate their need to be changed or go to the bathroom.

Activities and items my participant likes: (music, stories, coloring, physical games, independent play, group activities, reading, being read to, etc.). *

Behavior Concerns - Please share any behaviors we should be aware of (i.e. aggressive behavior, tantrums, wandering, etc.).

Behavior Modification Plan - Please explain in detail the behavior management plan being used at home and school to modify inappropriate behavior that may be exhibited. Our goal is to maintain consistency in the implementation of this plan.

What sensory tools or other items and routines are helpful in preventing or reducing or supporting behavior? (ex headphones for sound sensitivity, fidget toys, etc.)

My participant becomes upset or angry when:

I know my participant needs a break when:

My participant needs encouragement to:

My participant does not enjoy:

Personal goals for my participant:

Goals for church/special needs ministry for my participant:

Other things I'd like you to know about my participant:

If my participant does have a seizure, it looks like:

If my particpant is upset for more than ___ minutes, please contact me.

1-5 6-10 11-15 16-20 other

My participant's behavior may indicate a medical problem requiring immediate attention when:

How can we best partner with you to help your participant grow in a relationship with Christ?

Please indicate which best describes the level of support needed for aggressive behavior towards themselves or others

My child does not have agressive behaviors My child can occasionally have aggressive behaviors when triggered but does well in small groups My child often has aggressive behaviors towards themselves but is not aggressive towards others My child is frequently aggressive and requires a one on one for help regulating to prevent behaviors My child is frequently aggressive even with a one on one and needs separation from other children to keep everyone safe

Primary Contact Information

Mobile phone must be on during the event so that we can reach you in the event of an emergency.

Primary Contact First and Last Name

Relation to Participant

Mother Father Caregiver Sibling Aunt Uncle Grandparent Foster Parent Guardian Other

Other and/or Details (Relation to Participant) - If you marked other above, please describe

This address will receive a confirmation email

Secondary Contact Information

Secondary Contact First and Last Name

Relation to Participant

Mother Father Caregiver Sibling Aunt Uncle Grandparent Foster Parent Guardian Other

Other and/or Details (Relation to Participant) - If you marked other above, please describe

What did we miss? Please use this space as a place to let us know any additional information that would help us serve your loved one.

Thank you for trusting us with your kiddo! You will be hearing from a member of our team sometime the week before to follow up and be sure that we have everything prepared for you child.

Respite Night: Kids with Disabilities

Description

Please Fix the Following