Buddy Ministry Intake Form

To Be Filled Out By Parent or Guardian

    Section 1: Help us get to know your child with special needs

    Please help us get to know your child with special needs.

    Child's Name (required)

    Child's Grade (required)

    Child's Age (required)

    Gender (required)

    Child lives with:

    Father's/Guardian's name:

    Cell #:


    Mother's/Guardian's name:

    Cell #:


    Child's diagnosis, medical condition or learning difference that we should be aware of:

    A goal for my child while participating in the Buddy Program is:

    Section 2: Care Needs




    TypicalImpairedDeafHearing Aid


    Head controlRolls overSitsCrawlsWalks



    Can Communicate with others using:

    WordsPhrasesSentencesBabblesGesturesSign Language

    Language spoken at home:

    Can understand what others say:

    All the timeMost of the timeSome of the timeRecognizes voices of family members


    Is your child prone to seizures?

    **If "Yes", please fill out and send the "RUMC Seizure Action Plan"

    ALLERGIES and/or sensitivities: (Drug, Food, Other):


    Feeds self by using:

    spoonforkhandsrequires feedingbottle feddrinks from cup

    Special Diet:

    Toileting Skills:

    Toilets independentlyDiapersCurrently being potty trainedPotty trained, needs assistance


    How does your child indicate a need to use the toilet?

    Indicate special toileting needs/schedule:

    Behavior: (check all that apply)ShyOutgoingPlays AlonePlays in groupsAdapts to new situations wellAdapts to new situations with difficultyResponds to correction wellResponds to correction with difficultyIs sometimes destructiveSometimes threatens othersSometimes hit, bites, or hurts self/othersSometimes attempts to run away or wanderHyperactive and/or ADD

    My child responds to separation from his/her parents by:

    My child processes instruction or information best when (ie: visual, auditory, experiential learner)

    A trigger point for a possible "melt down" is:

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

    My child is best comforted by:

    My child may be trying to communicate their need for (describe)

    when he/she exhibits the following behavior

    My child lets someone know what he/she wants or needs by:

    What type of play activities does your child enjoy and/or participate in?

    My child becomes upset when/or does not enjoy:

    Are there any additional concerns not already addressed:

    Permission/Authorization Agreement

    Please read the following statements carefully and choose "I agree" in the designated space indicating that you have read, understand and agree to the provisions.

    I have fully disclosed to Reynoldsburg United Methodist Church all pertinent facts about my child's special needs and accept full responsibility for missing information.

    I will supply special food, drinks, snacks, and diapers/wipes for my child as necessary.

    I will remain on RUMC campus during the time my child is participating in any ministry event/program, unless it is specifically designated as a "Respite Event".

    I understand the nature of the program and do hereby release Reynoldsburg United Methodist Church and its representatives from any liability due to accident or injury incurred by my child.

    I authorize Reynoldsburg United Methodist Church to publish photos of my child (without his/her name) on our RUMC website and brochures for promotional purposes only.

    I have read and agreed the above/authorization statements and agree to the term designated in each:(please type your name)