Trinity EC Church
"Special Needs Form"

Please complete separate "Special Needs" forms for EACH & EVERY applicable child in your family.
Once you submit this form, the response page that appears
will provide the opportunity to return to a blank "Special Needs" form, if needed.

    STEP #1: CHILD'S NAME

CHILD'S NAME:

    STEP #2: ALLERGIES

ALLERGIES:

PLEASE PROVIDE A RESPONSE FOR EACH ALLERGY QUESTION FOR THE ABOVE-NAMED CHILD

ALLERGIES: YES / NO
Is this child allergic to peanuts/nuts?
Is this child allergic to Latex?
Does this child have other allergies?
(Food, drugs, other)		 If Yes, please list:

    STEP #3: SPECIAL NEEDS

SPECIAL NEEDS:
Please check all that apply to the above-named child

ADD/ADHD Downs Syndrome
Anger/Aggressive Behaviors Epilepsy/Seizures
Aspergers Hyperactivity
Autism/PDD Mental Health Issues
Bipolar Developmental Delays
Cerebral Palsy Migraines
Depression/Anxiety Obsessive-Compulsive Behavior
Difficulty Focusing Physical Movement Delay
Difficulty Following Directions Speech & Language Delay
Other Medical Issues

    STEP #4: SUPPORT

SUPPORT:
In order for us to be better able to meet your child's needs
either our Parish Nurse or a Special Needs Team member will be in contact with you.
Do you have a preference with whom you speak?

I WOULD LIKE TO BE CONTACTED BY:
Parish Nurse Special Needs Team member

Review information once more for completeness & accuracy before hitting the submit button.