Hope Ministry Intake Form

Your name *

Last name

Email address *

Age and Birthdate *

Gender *

Address

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Parent/Caregiver #1 Name *

Parent/Caregiver #1 Cell: *

Parent/Caregiver #2 Name

Parent/Caregiver #2 Cell: *

Emergency Contact *

Emergency Contact Cell: *

Siblings Names and Ages

MEDICAL

Please describe your participant's medical needs.

Check all that apply for participant *

Vision Impairment

Hearing Impairment

Motor Delay

Mobility Difficulty

Sensory Processing

Medically Complex

Emotional/Behavioral Challenges

Other

Participant Medications (Please note that we do not administer medication but do appreciate information on medications kept on hand in case of emergency): *

Emergency Action Plan *

Is participant prone to seizures? If yes, how do seizures present? What may trigger seizures? Please provide instructions on what to do in the event of a seizure while under our care: *

Allergies (environmental and/or food)? And are these life-threatening? *

Communication

Please describe your participant's communication preferences.

Preferred Mode of Communication *

Verbal Speech

Sign Language

AAC Device (or similar)

Visual Supports

Other

How may we encourage and facilitate communication with participant? *

Personal Care

Please share personal care needs here.

Toileting Needs *

Independent

With Assistance

Incontinence Supplies

Other

Getting to Know You

Please describe participant's interests and personality here.

What are participant's signs of enjoyment? *

What are participant's signs of distress, frustration, and/or unhappiness? *

What are participant's triggers? *

What calms or comforts participant? *

Goals for Participant at Church: *

Please share any other information you may want us to know, including any pertinent information from above where "other" was checked. *

Acknowledgement

Please read the below and type your name as signature.

I have fully disclosed all pertinent information about my participant and accept full responsibility for missing information.

I understand that Hope Ministry leadership is not medically or professionally trained, therefore, does not administer any medication. In case of emergency, Gateway has a Medical Response Team that will be called in addition to Parent/Guardian.

I understand that it is my responsibility to notify Hope Ministry staff or volunteers of my participant’s attendance to ensure proper assistance is provided.

I will remain on campus while my participant is under the care of the Hope Ministry.

I consent to my participant being photographed. The photographs may be used for positive publicity of the Hope Ministry.

I HAVE READ THE ABOVE ACKNOWLEDGEMENT AND AUTHORIZATION STATEMENTS AND AGREE TO THE TERMS DESIGNATED IN EACH.

Typed Name, serves as digital signature: *

Date: *

Address

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Gateway Baptist Church
info@gatewaybc.com
803-732-0590