Family Care Plan – CreekHelp

Child's Name: *

Child's Birthdate *

Ministry:

Parent/Guardian Name: *

Parent/Guardian Address: *

Parent/Guardian Address:

City

State/Province

Zip/Postal

Country

Parent/Guardian Phone Number: *

Parent/Guardian Email: *

CedarCreek Campus you attend:

Developmental Information

We desire to give every child an excellent experience. This care plan will help our team serve your child best. Complete all sections that apply.

Describe your child's communication (select all that apply)

What is your child's developmental age?

What age group does your child best associate with?

List any significant medical or psychological diagnoses:

Does your child have any allergies that we need to know about?

My child uses an Epi-Pen

Yes

What activities, toys and reinforcements does your child really enjoy and respond well to?

What activities, toys and reinforcements does your child dislike and/or respond poorly to?

Are there any concerns or challenges with eating/toileting? (please note if your child is not toilet trained.)

Please select any behavioral difficulties that apply to your child, and rate the frequency in which the behaviors occur: (1 = Occurs rarely; 5 = Occurs often)

Other

How do you comfort your child when he/she is upset? How do you handle your child's misbehavior? How does he/she react?

Is there anything else we need to know about your child to give them the best experience?

We look forward to partnering with you to provide the best care for your child! A campus representative will connect with you soon!

Signature *

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Todays Date & Time

Administration and use of Epi-Pen

By signing, I ( ) agree to waive and release any and all liability for CedarCreek Church in the administration and use of the Epi-Pen. I agree to forever release and discharge CedarCreek Church and its staff and volunteers from any and all liability, claims, actions, rights of actions, damages, and expenses, including attorney expenses, arising out of or resulting from any injury, disease, or death in the use, failure to use or the administration of the Epi-pen. If my child cannot administer the Epi-Pen themselves, I allow CedarCreek Church staff and volunteers to administer the Epi-Pen.

Signature

Clear

Todays Date & Time