Oak Park Church - Hope Class

Student's Contact Information

First Name

Last Name

Nickname / Preferred Name:

Birthdate:

Gender:

Male

Female

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Email

Siblings Names & Ages

Guardian's First Name

Last Name

Guardian Contact Information

Guardian's First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Email

Emergency Contact #1

First Name

Last Name

Relationship

Phone Number

Emergency Contact #2

First Name

Last Name

Relationship

Phone Number

History

Primary Disability

Known Allergies

Does this student have a history of seizures?

Is this student experiencing side effects due to medications?

Respiratory Concerns

Cardiac Concerns

Other Medical Information / Assistance Needed

Mobility

Additional Information Regarding Mobility

Nutrition

Food Allergies

Dietary Restrictions

Additional Information Regarding Nutrition

Daily Living

Check All That Apply

Attends School

Attends Day Program

Has a Job

Other

Additional Information Regarding Daily Living

OPC Special Needs Ministry Intake Form

Student's Contact Information

Guardian Contact Information

Emergency Contact #1

Emergency Contact #2

History

Communication and Cognition

Mobility

Nutrition

Daily Living

Social / Behavioral Issues