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  • SUNDAYS: 9AM & 11AM EST
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Pure Joy Special Needs Ministry Logo

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:*
MM slash DD slash YYYY
Address:*
Parent / Guardian Name:*
What service do you attend? (check all that you attend)*
Local Emergency Contact:*
In the event you cannot be reached, who should we contact.
• 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

(please provide as much information as you can)
(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:
 

Communication


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

Social Positive


Requesting attention
or assistance:

Verbal
Sign
Gesture

Requesting an object
or activity:

Verbal
Sign
Gesture
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
Sign
Gesture

Refusing an activity or a
request to do a task

Verbal
Sign
Gesture
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
Sign
Gesture
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
Sign
Gesture
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?
 

Social Play Triggers & Skills


Describe your child's behavioral response to the following situations below:

Given a new or difficult task to complete
A desired activity is interrupted
No interaction for 15 minutes or more
Changes in routine/schedule
Child cannot get something s/he wants
Child is left alone
Child can wait
Child can share and take turns with others
Child plays appropriately with toys
Please provide as much detail as possible:

Which of the following would your child find unpleasant?


Tactile Sensitivity
(Sensitive to touch)
Vestibular Sensitivity
(Sensitive to movement and/or balance)
Proprioceptive Sensitivity
(Sensitive in situations involving body movement)
Visual Sensitivity
(Sensitive to visual stimuli, visual discrimination)
Auditory Sensitivity
(Difficulty interpreting and integrating sounds)
Olfactory Sensitivity
(Difficulty processing smells)
Motor Planning
(Both fine and gross)

Activity / Reinforcer Preferences


Please use a scale of 1-5 (1 being the most enjoyable) to indicate your child’s preferences below:

Activities & Sports


Puzzles*
Games*
Books*
Sensory Toys*
Musical Instruments*
Computer Games*
Action Figures*
Painting*
Bowling*
Play Dough*
Books*
Sensory Toys*
Trampoline*
Biking*
Swing Set*
Slide*
Amusement Parks*
Swimming*
Roller-skating*
Skateboarding*

Television & Video


Disney Movies*
Animated Movies*

Dietary Restrictions & Independence

Does your child have dietary restrictions? Can your child feed his/herself independently? Does your child use utensils? Please describe below.
Describe the level of support needed in the restroom, if any.
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