We believe every child was created by a loving God designed for a purpose and that there is no such thing as a disabled soul.

Pure Joy Registration From

Using the form below, please provide all the necessary information needed to ensure we have the adequate personnel required to ensure the best care for your child during your preferred worship service.

"*" indicates required fields

General Information

Student's Name:*

First Last

Student's Age:*

Student's Date of Birth:*

Student's Gender:*

Address:*

Street Address Address Line 2 City State ZIP Code

Parent / Guardian Name:*

First Last

Contact Number:*

Email Address:*

What service do you attend? (check all that you attend)*

Saturday 5:00PM

Sunday 9:00AM

Sunday 11:00AM

Local Emergency Contact:*

In the event you cannot be reached, who should we contact.

First Last

Emergency Contact's Phone Number:*

Where can you be located while your child is with us?*

• Attending a Bible study? Please provide class time and room number.
• Please give us a general idea of where you sit during services should we need to find you.

Who is authorized to pick up your child?

First Name:

Last Name:

(siblings under 18 are not permitted to pick up)

Diagnosis & Education

What is your child's specific diagnosis?*

(please provide as much information as you can)

Please list any additional medical conditions:

(please provide as much information as you can)

Please list any medications your student currently takes and any known side effects related to the medication.

Use the plus icon to add more than one medication.

Medication Name:

Known Side Effects:

Does your child attend school?*

What school does your student attend?*

Placement Type:*

Communication

Please check each box that corresponds with how your child typically communicates.

Social Positive

Requesting attention
or assistance:

Verbal

Full Sentences

Multiple Words

Single Words

Other

Sign

Multiple Signs

Single Signs

Other

Gesture

Shakes Head

Points

Leads

Other

Requesting an object
or activity:

Verbal

Full Sentences

Multiple Words

Single Words

Other

Sign

Multiple Signs

Single Signs

Other

Gesture

Shakes Head

Points

Leads

Other

Please provide additional details:*

It looks like you checked "other" for one of the questions in the Social Positive section. Please provide the corresponding details for all applicable questions.

Social Negative

Requesting escape or
a break from something

Verbal

Full Sentences

Multiple Words

Single Words

Other

Sign

Multiple Signs

Single Signs

Other

Gesture

Shakes Head

Points

Leads

Other

Refusing an activity or a
request to do a task

Verbal

Full Sentences

Multiple Words

Single Words

Other

Sign

Multiple Signs

Single Signs

Other

Gesture

Shakes Head

Points

Leads

Other

Please provide additional details:*

It looks like you checked "other" for one of the questions in the Social Negative section. Please provide the corresponding details for all applicable questions.

Automatic Positive

Obtaining sensory input

Verbal

Full Sentences

Multiple Words

Single Words

Other

Sign

Multiple Signs

Single Signs

Other

Gesture

Shakes Head

Points

Leads

Other

Please provide additional details:*

It looks like you checked "other" for one of the questions in the Automatic Positive section. Please provide the corresponding details for all applicable questions.

Automatic Negative

Indicating pain

Verbal

Full Sentences

Multiple Words

Single Words

Other

Sign

Multiple Signs

Single Signs

Other

Gesture

Shakes Head

Points

Leads

Other

Please provide additional details:*

It looks like you checked "other" for one of the questions in the Automatic Negative section. Please provide the corresponding details for all applicable questions.

Behavior

List & Describe Behavior(s)

Please list and describe the behaviors we should be aware of. To add more than one, use the plus button.

Describe the behavior(s).

How many times it occurs daily?

How long does it last?

What do you do to redirect behavior?

Describe the likely function of these behavior(s)

Please list and describe when the behavior is more likely to occur. To add more than one, use the plus button.

Behavior

What does he/she get?

What does he/she avoid?