Family Engagement Child Profile
Your child profile helps our event organizers prepare for your best experience!
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's age
Child's diagnosis (if applicable)
Does the child require 1-1 support participating in recreation/social activities?
*
Yes
No
Child's Parent/Guardian Full Name
*
First Name
Last Name
Please list child's siblings, ONLY if they require on-site childminding:
*
Care awareness (please indicate and describe the child's needs)
*
Rows
YES
NO
Notes
Allergies
Hearing/Vision Concerns
Seizures
Adaptive Equipment
Toileting awareness (please indicate and describe the child's needs); Please note, caregivers may be asked to assist their children with toileting at events:
*
Rows
YES
NO
Notes
Wears diapers
Indicates need to use a toilet
Urinates in a toilet
Has BM in a toilet
Follows a timed routine
Level of Toileting Support (please check all that apply):
*
Independent
Full assistance required
Prompt needed to use facilities
Parent assistance required
Partial Assistance (pulling up pants, wiping, washing hands)
Safety (please indicate and describe the child's needs)
*
Rows
YES
NO
Notes
Will respond to name being called
Will run or hide
Puts inedible items in their mouth
Other Safety Concerns
What is the child's primary spoken language?
*
Communication (please indicate and describe the child's abilities and needs)
*
Rows
YES
NO
Recommendations for success
Words
Sign language
Vocal cues
Gestures
Devices
Behaviour (please list any or all you feel necessary for this environment)
*
Rows
YES
NO
Recommendations for success
Outgoing
Plays alone
Plays with others
Destructive to property
Shy
Bites, hits self or others
Flight risk
Separation anxiety
My child is best comforted by...
*
My child will let someone know they need/want by...
*
What types of activities does your child enjoy?
*
Submitted by (Caregiver full name)
*
First Name
Last Name
Caregiver Email contact
*
example@example.com
Caregiver Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Configurable list
*
Caregiver Signature
*
Date
*
-
Year
-
Month
Day
Date Picker Icon
Hour Minutes
Please verify that you are human
*
Submit
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