H4K | Hope Church

Parent/Guardian Information:

Parent/Guardian #1:

Cell #:

Parent/Guardian #2:

Cell #:

Street Address

City:

State:

Zip:

Email:

Emergency Contact

Name:

Phone Number:

Relationship to child/ren:

Consent and Release

Photo/Video Release: I grant permission for my child’s image to be used without identifying markers (name or personal info) in H4K promotional materials, including social media and print.

Yes No

Medical Treatment Authorization: In the event that I cannot be reached in an emergency, I hereby give permission for medical treatment to be administered to my child by a qualified professional/first responder.

Yes No

Signature of Parent/Guardian (By typing your name here it will count as your signature):

Date:

Parent Questionnaire for Children:

Our church cares for each participant in children’s ministry programming. These questions are asked for the benefit
of your child and so that we may provide the best experience and safest environment for everyone involved. Our
church and our children’s ministry workers respect your family’s right to privacy. Any information shared from this
form is communicated directly with those caring for your child and only on a “need to know” basis. Please answer
the below questions that apply to your child and that may help our church best minister to your child.

Child Information:

Name:

Age:

Grade:

My child is allergic to:

My child’s allergies can be life threatening:

…and require the use of an EpiPen?

My child is currently taking these medication(s):

My child has the following diagnosis, medical condition or learning difference:

My child is prone to seizures:

If “yes” what prompts the seizure and how we can prevent/respond:

My child’s main mode of functional communication is:

My child processes instruction/information best when:

Visual Auditory Kinesthetic

My child currently receives therapies and special instruction in:

My child has an Individualized Education Plan:

If answered “Yes”, please describe child’s IEP:

My child has the following area(s) of interest:

My child needs assistance with:

My child is uncomfortable with or has an aversion to:

A trigger-point for a potential meltdown is when:

When/if my child experiences a melt-down he/she calms when we:

My child is really picky about:

My child may be trying to communicate their need for (describe need) _______________________ when he/she exhibits the following behavior (describe behavior):

My child’s behavior may indicate a medical problem requiring immediate attention when:

Is there anything else we should be aware of?

Add child