Abilities Ministry: Registration

Thank you for connecting with the 12nine Abilities Ministry at Bayside Baptist Church!
The information on this questionnaire is strictly for our team leaders to access in order to provide the best care and experience for each of our 12nine Ministry students. This information will be kept confidential and is intended to help our team understand the needs of each individual participant and to enhance their overall experience at Bayside Baptist Church.

Please plan to spend up to 30 minutes completing this form. It must be completed in one sitting. You cannot save this form and return to it at another time. If you need more time to complete this form, you may want to save your answers in a document on your computer and then copy and paste the information into this form when you are ready.

Lastly, for questions that do not apply to your 12nine Ministry student, please answer 'n/a'.

Your name *

Email address *

Your relationship to applicant *

Phone number *

Emergency Contact and Relationship *

Phone number *

PARTICIPANT INFORMATION

First Name *

Last Name *

Nick Name

Phone number *

Birthdate *

Gender *

Address *

Does student have any siblings? *

Yes

If yes, what are their names and ages?

STUDENT INFORMATION

We collect the following information to make sure the student has the best experience while in our care. Please be as open and honest when answering these questions; your student will not be turned away nor discriminated against because of what is noted.
If the question does not apply, please type N/A

What are his/her strengths? *

What does he/she like or dislike to do for fun or to talk/think about? *

What does he/she know about Jesus? *

How does he/she communicate ? *

(vocal, non-verbal, knows some words, signs)

Describe the student’s disability, including diagnosis *

Describe any medical issues *

How is his/her vision and hearing ? *

(legally blind, sensitive to light, wears hearing aids, prefers headphones)

Does he/she have any restrictions from physical activity ? *

(falls easily, fragile, needs a helmet)

List dietary restrictions, if any *

(i.e. gluten free, dairy free, no church snacks)

List and explain all behaviors he/she displays. *

(You may copy and paste any of these or write your own: biting self or others, stimming or rocking, crying, elopement/wanders/runs away, meltdown/tantrum/emotional outbursts, verbal outbursts/cussing, scratching self or others, hair pulling self or others, prefers to be alone, sudden/unexpected hitting self or others, struggles with transitions, spitting, kicking, howling/vocalizes other sounds, throwing objects, putting non-food items in mouth, pinching self or others.)

What triggers any of the above behaviors? *

(i.e., certain words, behaviors, environmental conditions, touch, loud music, crowds)?

What signs does your student give that indicates she/he may be getting upset ? *

(gets quiet, starts pacing, raises voice)

What else can we do to help your student have the best experience while in our care? *

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