Special Friends Ministry Survey

Please note that Revival Kids will connect with you after filling out the form. We communicate with families weekly to ensure we have the staff to accommodate all our Special Friends.

Your name *

Email address *

Child Name *

Parent Name *

Phone number *

Child's Age *

Child's Birthday (mm/dd/yyyy) *

Special Need? *

1. How did you learn that your child had a Special Need? At what age did you know? *

2. What have been the problems/challenges you and your family have faced? *

3. What have been your experiences with school personnel? What have they done that was most helpful? Most hurtful/harmful? *

4. What advice would you want to give us so your child has the best possible experience? *

5. What are some things your child likes to do with the most interest and enthusiasm? *

6. How does your child act when they are excited? *

7. How does your child act when they are upset? What is soothing? What should we try? *

8. What kind of situations does your child find stressful or upsetting? *

9. What have you noticed about your child’s sensitivities, if any: *

To touch, such as physical sensations that your child wants to avoid?
To light or brightness, such as any attractions or avoidance to light?
To sound, such as any attractions or avoidance to sound?

10. Is your child on any medications or have a special diet? *

11. Are you comfortable with staff making physical contact with your child? Redirecting, leading to another activity, preventing injuries, etc. *

12. Is your child a runner? (tend to run as soon as door opens, gate, etc) *

13. Can your child use the restroom by his/herself? How will we know when they need to use the restroom? *

14. Can your child feed themselves? Do we need to give small pieces one at a time? One bite at a time? *

15. Will you be bringing a snack? *

16. Does your child communicate with some signs? What are they and what do they mean? Do they use a picture exchange communication system or electronic device such as an iPad to communicate? *

17. Is there any information we should know related to food allergies, environmental health or safety, or any other individual safety needs? *

18. How would your child like to be introduced to the staff and the other children in the ministry? *

19. What are your concerns, if any, about your child’s participation in Children’s Ministry? *

20. Is there anything else you would like to share that will help us make this a positive experience for your child? *

I understand that Revival Kids will connect with families each week before attending church. This is to be certain that Children's Ministry has the staff to accommodate our Special Friends. *

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