Five Lakes Kids and Students: Special Needs Intake Form

The information provided in this survey will be kept confidential to Kid’s Ministry/Student Ministry Staff.

At Five Lakes Church, we believe that every kid/student matters because each one is a soul. Every soul needs to know that Jesus loves them. Every kid/student needs a space where they can grow closer to God and a church that will welcome them, regardless of their needs. To ensure all can participate in our ministry, we ask that you take some time to complete this form so that we can learn more about the special needs of your child. We will use this information to ensure the safety of your child and to provide the necessary supports so that they can best participate within our ministry.

In Five Lakes Kids, each child registered with our buddy program will be assigned a buddy whom you will meet at our check-in desk. These buddies are scheduled through our Special Needs Coordinator. The buddy will carry a personalized backpack that will contain the information in this form, any sensory items needed, and some preferences or 'hacks' that will help guide and direct your child. We're so glad you're here!

Your name *

Email address *

Phone number

Child's First Name *

Child's Last Name *

Please describe your child's special needs: *

Please list any special medical needs or allergies:

Check if your child utilizes an EpiPen

Please list your child's strengths and interests/likes:

Please list your child's dislikes or triggers:

Please describe any strategies that help your child calm down, focus, or transition to new tasks:

If your child attends school, do they receive any accommodations? If so, please describe:

Please share any additional information we may need to know about your child:

Is there anything Five Lakes Church can do to support you, as a parent, or your family?

A copy of your responses will be sent to your email address.