Special Needs

New Student Registration

The following questions are asked for the benefit of your student, and so that we may provide the best experience and safest environment for everyone involved. Our church leaders and ministry volunteers respect your family's right to privacy. Any information shared from this form is communicated directly with those caring for your child and only on a "need to know" basis. You will be contacted by a Together at Warren staff member within 24 hours, Monday – Thursday, after submitting this form.

You must meet with and/or speak to a Together at Warren staff member prior to your first visit so we can be fully prepared to care for your student.

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Student Information

Student Name(Required)

First Last

Gender(Required)

Birth Date(Required)

What school or center does he/she attend?*(Required)

Parent / Caregiver Information

Parent / Caregiver Name(Required)

First Last

Relationship to Student(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Home Phone(Required)

Cell Phone Number(Required)

May we contact you through text message?(Required)

Check the times and days you are interested in having your student attend Warren.(Required)

Sunday morning 9:30

Sunday morning 11:00

Wednesday evening 6:15

Where will you be while your child is attending Together At Warren?(Required)

The parent/caregiver must be on the Warren campus while the student attends Together at Warren on Sunday morning.

Please give the name and room number of your Life Group.(Required)

Please select the Worship Service you are attending.(Required)

Student Specific Information

Where would you prefer your student be placed?(Required)

Note: Ministry leaders with experience are consulted for this decision.

Is your child verbal or nonverbal?(Required)

Is your student physically harmful to himself/herself or others?(Required)

What is the Chronological Age of your student?(Required)

What is the Developmental Age of your student?(Required)

What are some things your student loves to do or has a special interest in?(Required)

What's the best way to communicate with your student? (simple sentences, sign language, picture cards, etc.)?(Required)

What devices, equipment, and/or items does your student successfully use at home or school?(Required)

Does your student have any allergies or medical needs we should be made aware of? (seizures, food, EpiPen, etc.)(Required)

Can your child have animal crackers, gold fish, and/or pretzels for snack?

Additional notes about Snack and Food.

About your Student

Please share your students’ diagnosis or disability.(Required)

Does your student elope (escape)?(Required)

When does this behavior seem to happen?(Required)

Eloper/Runner Consent(Required)

in case of an emergency, Thrive has permission to share my student's photo as needed in order to locate him/her.

Date(Required)

Are there any words or strategies that help stop and/or prevent it?(Required)

What are your main concerns for your student at this event/service?(Required)

Please explain any sensory or behavioural needs your student has.(Required)

Does your student need assistance in the restroom?(Required)

Please explain.(Required)

Additional Parent Information

Sunday Life Groups*(Required)

Would you like some additional information about joining an adult Life Group?

Opportunities to Serve

Are you interested in being a part of the vision of utilizing your gifts and talents to serve and support one another? Check all areas you are interested in learning more about as you consider where you might serve.

Together At Warren - Special Needs Ministry

Preschool Ministry

Children's Ministry

Middle School

High School

Other

Is there any other information you would like our team to know?(Required)

If yes, please explain.

Photo Release(Required)

I do/do not (select one) hereby give permission for my student, to have his/her photograph/video,taken to be used in publicity,illustration, and/or web content in connection with the Together At Warren Special Needs Ministry at Warren Baptist Church.

Medical Consent

In case of emergency, Together At Warren has my consent to authorize medical care for my child/student listed below:

Student's Name(Required)

First Last

Diagnosis or disability(Required)

Student’s Primary Physician(Required)

First Last

Physician’s Address(Required)

Street Address City State ZIP Code

Physician's Phone(Required)

Hospital Preference(Required)

Current Medications(Required)

Please separate medication names by commas.

Does your student have a history of seizures?

Note: If the student has a history of seizures, please complete the Seizure Action Plan form by clicking the next button below.

Minor First Aid

Minor First Aid(Required)

I give Together At Warren permission to administer any necessary minor first aid which may include ice and/or bandage as indicated:

Your Name(Required)

First Last

Relationship to student(Required)

Phone Number(Required)

Emergency Contact

If unable to contact me, please call:

Name(Required)

First Last

Phone(Required)

Name(Required)

First Last

Phone(Required)

Seizure Action Plan

Student's Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Parent/Caregiver Cell Phone(Required)

Emergency Contact Name(Required)

First Last

Phone(Required)

Diagnosis(Required)

Seizure History(Required)

Contact Parent/Caregiver If(Required)

Call 911 If(Required)

Is Diastat/Versed or any other medications prescribe to this student that may significantly alter vital signs or level of consciousness? (if yes/other, list it below)(Required)

List More Here:(Required)

If Diastat/Versed or any other seizure rescue medication is needed, it will be administered by the parents/caregivers. If the parents/caregivers are unable to reach the student within the ________ minutes required, a medical licensed trained professional will administer the seizure rescue medication (such as: Diastat or Versed)(Required)

*Also provide physician signed instruction for seizure rescue medication which includes: dosage, how it’s given, and under what circumstance it should be given.

Does the student have an implanted device to reduce seizures?(Required)

Any additional information/instructions:(Required)

Consent

By placing your information in the following area, you are acknowledging that all information regarding the Seizure Action Plan is true to the best of your knowledge. Also by filling out your information in this area, you are giving permission to the representatives of Warren Baptist Together At Warren Special Needs Ministry to act as you have indicated on behalf of your child/student.

Name(Required)

First Last

Relationship to student(Required)

Date(Required)

How did you hear about Together At Warren Special Needs Ministry?

Website

Social Media

Newspaper

Billboard

Word of Mouth

Life Group Class

Home Group

Other

CAPTCHA

This field is for validation purposes and should be left unchanged.

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New Student Registration