denton bible church’s special needs ministry...special needs coordinator and assistant coordinator...

1 HisWorkmanshipMinistryIndividualIntakeStudentName:

DentonBibleChurch’sSpecialNeedsMinistry

IndividualOverview/QuickGlanceForm,pg2

Individual’sMedical&HealthNeeds,pg3

Individual’sAbilities&CareNeeds,pg4

Individual’sBehavior&InterventionNeeds,pg5

Parent/Caregiver/GuardianConsents,pg6

MinistryProgramming&Policy(forParents/Caregivers),pg7

Thankyouforfillingouttheseforms.Pleasereturnpages2-6totheministryCoordinator.Werespectyourfamily’sprivacyandwillonlyusethisinformationforministrypurposes.Pleaseanswerthequestionsattachedthatapplytotheindividualwithadditionalneedsinorderthatwemaybestministertothemandtoyourfamily.


Individual Overview/Quick Glance Date: ______________ Student’s name__________________________ DOB, Age & School year ______________________ Parent’s/Guardian Contact Name(s) ________________________________________________________ Address ________________________________________________City ____________ Zip __________ Phone #’s of Parent/Guardian/Caregiver Cell #1__________________ Cell #2__________________ Email Address(es) _____________________________________________________________________ Student’s home placement: With parents _______ Group Home _______ Other _______ Diagnosis, medical condition or learning difference: Autism ______ ADD/ADHD ______ Sensory Processing Disorder______ Mental Health (Bipolar, OCD, Anxiety)_____ Down Syndrome _____ Emotionally Disturbed _____ Medically Fragile; Seizures ______ Post Traumatic Stress Disorder______ Intellectually & Developmentally Delayed ______ Oppositional Defiant Disorder _______ Blind or Deaf (circle) ______ Other: _______________________________

Student Safety Concerns: Student is prone to seizures (circle one) Yes/No How to respond: _____________________________ Student prone to elopement (circle one) Yes/No How to prevent: _____________________________ Student’s allergies and/or food sensitivities: ____________________________________ Epi Pen? _____ Student’s interests used to engage them?___________________________________________________ Student’s placement in school: Special Ed ______ Regular Ed ______ Regular Ed with assistance ______ Special schools/programs __________________________________ Any known struggles in school setting?_____________________________________________________ Strategies used in classroom at school to help student? (see below): Picture Schedule____ Social Story_____ Peer buddy_____ Preferential seating____ Frequent breaks ______ Offer choices ______ Alternate/reduced tasks _____ Rewards for desired behavior _____ example: _________________ Ignore minor behavior_____ Other__________________________________________________ Level of participation/behavior modifications: Student seems most relaxed in settings alone, with few people/peers, among many. Student does/does not enjoy music and/or would/would not enjoy a large group worship. To transition student needs strict routine/no transitions, count down/prompts, no assistance. If any, which would be a trigger-point for resistance, frustration, or behavioral problem for student: Transition ___ Noises___ Touch___ Peer interaction___ Lighting___ Other__________________ To calm student: Given space___ Taken to a quiet spot___ Given new task___ Other_______________


Individual Medical Information: Student Name: _______________________ DOB:______________ Parent/Guardian/Caregiver name(s): _____________________________Phone:________________________ Briefly describe your individual’s medical condition/diagnosis/disability/learning difference and age of cognitive understanding: __________________________________________________________________________________________ __________________________________________________________________________________________ List any chronic health problems (e.g., asthma, pressure sores, cough) and treatments of which the staff and volunteers should be aware of: __________________________________________________________________________________________ __________________________________________________________________________________________ List medications that are administered regularly: __________________________________________________________________________________________ __________________________________________________________________________________________ List drug allergies: __________________________________________________________________________________________ __________________________________________________________________________________________

Is the individual a carrier of an infectious or contagious condition? No _____ Yes _____ (explain) _______________________________________________________________________________________________ Any physical conditions, past operations or injuries which restrict activity? No _____ Yes _____ (explain) (i.e. G-tube)________________________________________________________________________________

Does the individual have seizures? No ______ Yes ______ (please complete below) Type of Seizure: __________________ Current Status: Controlled _____ Active ______ How often? ______

Has the individual been hospitalized or treated in ER recently? No _____ Yes _____ (please explain below)

_________________________________________________________________________________________ In case of emergency, which local hospital would you prefer? Denton Regional ____ Denton Presbyterian____ (see Consent form for more information regarding emergency protocol)


Individuals Abilities & Care Needs: Vision: Normal _____ Impaired _____ Blind _____ Assistive devices used? _____ Hearing: Normal _____ Impaired _____ Total loss _____ Assistive devices used? _____ Speech: Normal _____ Impaired _____ Nonverbal _____ Assistive devices used? _____ Communication: Speech _____ Gestures _____ Sign Language _____ Does individual understand what is being said to him/her? Yes _____ No _____ ________________________________________________________________________________ Can individual express his/her basic needs? Yes _____ No _____ How?___________________________________________________________________________ Mobility: Walks _____ Wheelchair _____ Walker _____ Crutches ______ Cane _____ Describe transfers, if applicable _________________________________________________________ Adaptive Devices: AFO’s _____ Prosthesis _____ Helmet _____ Other ________________________ Toileting: No Assist _____ Partial Assist _____ Total Assist _____ Wears diapers/pull ups? Yes _____ No _____ Special toileting needs/schedule? _______________________________________________________________ How does individual indicates needs? Signs _____ Gestures _____ Verbal_____ Other/Explain__________________________________________ Eating Habits: Feeds self _____ Uses special utensils _____ Needs prompts _____ Requires full help_____ Bottle fed _____ Eats by G-tube _____ Additional instructions: _____________________________________ Special diet: No Nuts _____ No Gluten _____ No Dairy _____ Other _______________________________ Additional Information: What is the individual’s understanding of God, a relationship with Christ and baptism? ____________________ __________________________________________________________________________________________ Activities/interests the individual really loves (indoor/outdoor):_______________________________________ __________________________________________________________________________________________ Skills/abilities the individual is good at: __________________________________________________________ __________________________________________________________________________________________ Does the individual have any specific fears? No _____ Yes _____ Explain: ____________________________


Individual’s Behavior & Intervention Needs: Socially: Outgoing ____ Shy _____ Explain: _________________________________________________ Adapts to new situations/environments: Well _____ With difficulty _____ Successful ways to assist in adapting: _________________________________________________________ Responds to correction: Well _____ With difficulty _____ Methods of correction used at home/school (i.e. time out, removing privilege, etc): _____________________ __________________________________________________________________________________________ Behavioral Challenges: (check all that apply): Destructive _____ Threatens _____ Runs Away _____ Hits Others ______ Hits Self _____ Bites Others _____ Bites Self _____ Other ____________________________________________________ Triggers for Behavior(s) ____________________________________________________________________ Frequency of Behavior(s) ___________________________________________________________________ Successful ways to deal with behavior(s) _______________________________________________________ If the individual is having a difficult time, at what point would you like us to contact you? __________________ __________________________________________________________________________________________ Special Needs Coordinator and Assistant Coordinator are trained in Crisis Prevention Intervention including de-escalation and restraint. Special Needs Ministry team leaders and Children’s Ministry team leaders are educated in de-escalation techniques. See Consent to Restrain on page 6.


Permissions/Authorization Agreement: Please read the following statements carefully and initial in the designated space indicating you have read, understand, and agree to the provisions.

In case of emergency or accident, I understand that the Denton EMS (911) will be called. I authorize EMS to administer any medical treatment, medication, or appliance deemed necessary by EMS. I also authorize transportation by EMS to the nearest appropriate medical facility, as determined by EMS. I understand that I will be responsible for payment of all EMS, hospital, and physician charges for emergency services to the individual the form is completed about.

I have fully disclosed to Denton Bible Church all pertinent facts about the individual’s needs and accept full responsibility for failure to do so.

______I give permission for the these facts to be shared with staff and volunteers who will have contact with my child.

I give permission to those trained in Crisis Prevention Intervention to provide restraint for my child or individual in my care who's behavior is putting themselves or others at risk.

I give permission for the individual to be photographed/videoed. The pictures/video may be used for press releases, journal articles, or other positive publicity.

______I give permission for the individual to be photographed/videoed and photographs/videos used in class and for classroom use only.

I will remain on Denton Bible Church campus during the time the individual is participating in any ministry event/program.

I will respond to cell phone and pager notifications from the individual’s class. I RELEASE, WAIVE ALL CLAIMS AGAINST, DISCHARGE AND COVENANT NOT TO SUE THE CHURCH, OR ANY OF THE CHURCH’S ELDERS AND EMPLOYEES, INCLUDING BUT NOT LIMITED TO PASTORS, STAFF AND OTHER EMPLOYEES, MEMBERS, REPRESENTATIVES, OR VOLUNTEERS (COLLECTIVELY REFERRED TO HEREIN AS “CHURCH REPRESENTATIVES”) WITH RESPECT TO MY CHILD’S PARTICIPATION, INCLUDING WITHOUT LIMITATION ATTENDANCE AT, OBSERVATION OF, OR BEING OTHERWISE INVOLVED IN THE ACTIVITY (“PARTICIPATION”), WHETHER MY CLAIM OR THE CLAIM OF ANYONE ON MY BEHALF IS BASED ON OR ARISES OUT OF PERSONAL INJURY, DEATH OR INJURY TO PROPERTY AND WHETHER SUCH CLAIM IS CAUSED BY THE NEGLIGENCE OF THE CHURCH OR ANY OF THE CHURCH REPRESENTATIVES.

I ASSUME FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE DUE TO THE NEGLIGENCE OF THE CHURCH OR ANY OF THE CHURCH REPRESENTATIVES WITH RESPECT TO MY PARTICIPATION IN THE ACTIVITY. PARENT OR GUARDIAN OF INDIVIDUAL, ON BEHALF OF INDIVIDUAL:

Parent/Guardian Signature:

Printed Name:

on behalf of __________________________________________________[individual’s name] Date: _____________________


His Workmanship Programs & Policy For the safety of each student and volunteer in His Workmanship, the special needs ministry, and the Children’s and Students’ ministry, we ask that the following policies be enforced with no exceptions:

§ Aparent/caregivermustattendclassinitiallywiththenewstudentwhohasadiagnosis,requiresadditionalsupportsforinclusion,and/orisinaspecialeducationclassforschool.Parents/Caregiverswillbeaskedtoprovidebasicinformationaboutthechild’sneeds,abilities,andcurrentsupportsthatcanbecarriedovertoSundaySchool.

§ Intheeventthatabuddywillbeneededtoassistthestudentandtheclassroomstaffisunabletomeettheirneedsuntiloneisavailable,aparent/caregiverwillbeaskedtostaywiththestudentinclasseachweekuntilabuddyisinplace.

§ Beforethestudentwhoneedsabuddyforinclusionisallowedtobestayinclassconsistentlywithoutaparent/caregiver,aparent/caregivermustcompleteandreturnanintakequestionnaire(s),whichwillbehandedoremailedtothemfromAmandaVaughn,theSpecialNeedsCoordinator.

§ AparentorguardianmuststayontheDBCcampusforthedurationoftheclassinordertobeabletodropoffastudent.

How Can We Help You?

Our purpose is to facilitate inclusion inside the life of the church For the individual with additional needs and for their family.

Whatbestfitsyourindividual’sneeds?Inclusion–studentattendsclasswithsameagepeerswiththehelpofabuddy,whenneeded.Alternateclassroom–studentattendsclasswithpeersinaclassroomspecificallydesignedtoprovideadditionalsupport,structuredsettings,andageandabilityappropriateteaching. Buddy for Me – (9 or 11a) (ages from infant to adult) Inclusion and Alternate Classroom Program designed to enlist a volunteer to help a student participate in their class and engage with their peers each Sunday. RISE Jrs. – (11a) (kids 3-9 yrs) Alternate Classroom (downstairs) This class is set up with a structured, multi-sensory approach to engage the kids depending on their sensory needs and their level of understanding. RISE Tweens – (11a) (10-15 yrs.) Alternate Classroom (Student Ministry Bldg.) This class caters to the individual needs of those needing a more structured, sensory-friendly environment. RISE Adults – (9 & 11a) (16+ yrs) Alternate classroom (Student Ministry Bldg.) This class brings together individuals with various mental & physical needs to grow disciples and build community. Parent Survival Night –Care Group or Respite - A once a month opportunity for parents of children with a disability to participate in prayer and sharing in a safe environment. **Not meeting in the Spring of 2018. Get connected. Join our group, His Workmanship, on The City. Contact: Amanda Vaughn, Coordinator, (940) 297-6781, [email protected]

denton bible church’s special needs ministry...special needs coordinator and assistant coordinator...

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