1. education
2. alumni and reunions

Child & Family Information
Date:_________Name___________________________________DOB________Grade________
Family Information
Mother ______________________________ May pick up child?
Father _______________________________ May pick up child?
Yes
Yes
No
No
Other Children ________________________ DOB ____________ Grade in School ___________
Custody concerns ______________________________________________________________
Contact Information
Address _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Home Phone ________________________ Cell Phone(s) ______________________________
Email ________________________________________________________________________
Please tell us about your child’s strengths: (Go ahead…BRAG!)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list your child’s interests: (This helps us to form relationships.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please tell us about any health and medical needs that would allow us to best support your
child and keep him/her safe: (Circle/explain)
Epilepsy_______________________________________________________________________
Food Allergies__________________________________________________________________
Food Sensitivities________________________________________________________________
Other medical or learning issues____________________________________________________
Child & Family Information
Please give us any additional information that would make you feel comfortable as we work
with your child.
______________________________________________________________________________
______________________________________________________________________________
Please circle any tasks with which your child requires help. (Please note: nothing surprises us
or makes us nervous…we just want to be prepared to welcome your child, keep him/her safe
and set up everyone for success at church.
Remaining on task
Making friends
Understanding directions
Using the bathroom
Eating
Staying in the class
Staying in the building
Communicating
Reading aloud
Writing
Large-motor activities
Small-motor activities
Taking turns
Separating from parents
Staying calm at church
Managing loud noises
Managing a large space
Managing crowds
Other
Help us understand the above issues by completing the following phrases:
When my child gets angry or upset, he/she will _______________________________________
______________________________________________________________________________
The best way to calm my child is ___________________________________________________
______________________________________________________________________________
If my child needs the restroom, he/she will communicate by ____________________________
______________________________________________________________________________
My child needs some prompting to maintain attention or take turns. The best things to do are
______________________________________________________________________________
______________________________________________________________________________
I know my child needs a break when _______________________________________________
______________________________________________________________________________
How can we partner with you and your family as you work together to grow in Christ?
_______________________________________
Parent Signature
______________
Date
Child & Family Information
This resource is provided FREE of charge by the team at Key Ministry. Please let us know how
we can support you and your ministry.
Our team provides the following resources to churches FREE of charge…
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Best Practices Online Resources
Opportunities to network with other churches
Phone & Skype Consultation
On-site Consultation & Training
Celebrating your successes
Local & National Conferences
Praying for you!
Please keep in touch! We would LOVE to hear from you.
Key Ministry
8401 Chagrin Road, Suite 14B
Chagrin Falls OH 44023
Phone: 440/247.0083
www.keyministry.org
www.FREERESPITE.com
If you’ve been blessed by our ministry we would love for you to
consider supporting our mission financially. You can donate today by
visiting our website or you can scan this code with your smart phone
to view our Key Catalog. Thank you for your support!