Friendship Class & Respite Intake Form

Contact Kris Volkir, Disability Ministry Director, with questions at kris@vc.church

 
CONTACT INFORMATION
Student's Name *
Student's Name
Student's Gender *
MEDICAL CARE
Yes or No? If Yes, please detail the side effects.
Seizures? *
Respiratory Problems? *
Does your child have any food or environmental allergies we should be aware of? *
Assistance needed when eating/drinking? *
Toileting *
Mobility? *
Primary Care Physician Phone # *
Primary Care Physician Phone #
Insurance Provider ID # Group # Billing Address /phone # of provider
Please type your name below (in lieu of written signature) if you give your consent for emergency medical treatment in case of emergency or accident.
SPEECH & COGNITION
The student communicates in the following ways: *
Hearing problems? *
Vision Problems *
Following directions? *
SOCIAL & BEHAVIORAL
Behavioral tendencies? *
Check all that apply
Name, Age, and are they attending Respite, too?
Photo Release: *
Please check yes or no if it is okay to take photos of your child(ren) to be used in print or web material associated with Valley Community Church.