Plan a visit
Plan a visit
Can-Do Child Profile and Placement
Date of Birth
Date Format: MM slash DD slash YYYY
Address Line 2
State / Province / Region
ZIP / Postal Code
Does the child live with both parents?
Are there any custodial arrangements that Grace Chapel needs to be made aware of?
Please list any siblings & their date of birth
We believe everyone is made in the image of God. A diagnosis does not define an individual but “child of God” does. However, knowing your child’s diagnosis will help us serve your family better.
Please check any special need/s that your child has been diagnosed with:
Autism Spectrum (ASD)
Traumatic Brain Injury
List any other diagnosis that wasn't listed and/or any important infomation we need to know about their diagnosis
In your own words, describe your child. Please let us know what makes your child unique:
Please list any medical issues/special concerns:
Is your child toilet-trained?
How does your child communicate their toileting needs?
Is your child independent with all toileting/self-care needs? describe the assistance they will require. If assistance is required, please
***Please note as stated on page 11 of Grace Chapel Children’s Ministry Policy and Procedures: After the age of 4, parents or legal guardians will change all special needs individuals.
Does your child have any food allergies? If so, please list:
Is your child independent with feeding or require any special assistance?
Does your child have any dietary restrictions?
Is your child verbal or non-verbal?
If non-verbal, do they communicate using ASL, gestures, or any assisted technology devices?
Behaviors (positive and negative) exhibited at home (parent input):
Behaviors (positive and negative) exhibited at school (parent and/or teacher input):
Does the child have a behavior plan at home or school? Would you be willing to provide a copy to be kept in a confidential file at church?
What are effective ways to reinforce positive behaviors? (Ex. praise, physical touch, small token/prize, quality time)
What are effective ways to discourage negative behavior? (Time out, ignoring behavior, withholding, behavior chart)
Brainstorm about how to make Sunday morning class time a positive experience for child: