Guardian Angels

* Name of person filling out this form

* Relationship to Child

* Name of Child

* Address

* Phone

* Text

* Email

* Birth Date

* Age

* Developmental Age

* What is his/her diagnosis or disability?

* Foods to avoid/allergies:

* What method of liquid does your child use?

* Does he/she require assistance while eating or drinking?

Health

* Does he/she have seizures? If yes, what type:

Besides contacting you immediately, what should we do if your child has a seizure while in our care?

* Is he/she on medication? If yes, what type?

Do we need to be aware of any side effects of medication? If yes, explain:

Behavior:

* Describe your child's behavior. Is he/she aggressive, a flight risk, self abusive, etc.? Does he/she bite, hit, throw things, run away, yell, etc?

* What can we do to redirect inappropriate behavior? Please give us examples of what you do at home or school:

* Does your child have any special fears?

Toilet/Hygiene Needs:

* Does your child use the toilet independently:

* Does your child use the toilet with supervision:

* Should volunteers ask if he/she needs to use the toilet?

* Does your child wear diapers or pull-ups?

Communication

* Is your child predominately:

* How well does your child understand directions?

* What works best when communicating directions and requests?

* Does your child understand some sign language?

* Can your child read or write? Explain:

* What words, sounds, and word approximations does your child say and what do they mean?

* What can you tell us about your child to help us better care for him/her?

Agreement

Please read the following statements carefully and check the box indicating that you have read, understand, and agree to the following:

* I have disclosed to Calvary Church all pertinent facts and medical conditions about my child and accept full responsibility for failure to do so.

* I have disclosed all known allergies to Calvary Church.

* I understand that no medication will be given by volunteers.

* I understand that the Guardian Angel Program is for children pre-school through age 11.

* In case of emergency or accident, I understand that I will be contacted immediately via cell phone. If necessary, 911 will be called (I have listed current medications).

* My child has not shown ANY symptoms of illness within the last 24 hours.

* I understand that Guardian Angel volunteers will do everything possible to redirect inappropriate behavior.

* I understand that Calvary does not yet have the facility to accommodate changing diapers or otherwise soiled clothing, and I will be contacted if needed.

Please know that submission of this form does not secure participation in the Guardian Angels program. You will be contacted by our Children’s Pastor or Guardian Angel Coordinator to discuss placement in the program.

* Signature of Parent or Guardian

Guardian Angels Application