Woodvale Kids Inclusion Form

Please indicate child's name

Your name *

Email address *

Child's Name *

Preferred Name/Nickname: *

Name *

Relationship to child *

Parent/Guardian #1

Address *

Phone number *

E-mail Address

Parent/Guardian #2 (If applicable)

Name

Relationship to child

Address

Phone number

E-mail Address

Other Information Needed

Emergency contact (other than parents):

Persons authorized to pick up (other than parents):

School student attends:

Medical & Health Information

Medical Diagnosis:

Diagnosis in lay terms:

Does your child take medication?

Yes

If answered YES, types of medication:

Does the child have seizures?

Please list any allergies or food sensitivities:

Are there any foods or drinks that we should not give your child?

Is assistance needed with eating/drinking?

Is help needed for personal hygiene?

Please discuss your child's communication skills:

Summarize your child for us in one sentence:

Are there specific triggers that tend to cause your child to become anxious?

What sorts of things do you do to soothe your child when he/she is anxious?

What strategies have worked well with your child in school?

Are there any strategies that have NOT worked well for your child in school?

Child's Profile

Does your child have any special gifts/talents?

What are your child’s strengths?

Any additional information we should know?

Child’s understanding of God/relationship with Christ:

Upload a photo of your child *

To ensure that we give the best care to your child, please attach a photo so our leaders in the room would know who the child is.

No file currently selected

Choose 1 file. Maximum file size 10 MB.

Medical Release *

If at any time medical or first aid treatment is required due to circumstances such as an accident, sudden illness or emergency, I authorize that treatment may be given, including necessary anesthetic, by a private physician or hospital. I also consent to emergency transportation, if necessary.

Waiver *

I understand that the Oasis program at Woodvale Pentecostal Church is a volunteer-run program. I/We permit the child listed on this form to take part in the Children’s Ministries at Woodvale Pentecostal Church (WPC) and agree to waive any claims upon WPC (or any of its agents) in the event of injury, loss, or damage (however caused), that may be sustained by the above-mentioned child, while taking part in the programs, and in all matters relating to the ministries organized by WPC. I/We understanding the risks involved in the nature of these programs.

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