IBC Intake Form: TLC Ministry

These questions allow us to provide the best experience and safest environment for all of our friends within the ministry. Our church leaders and ministry volunteers will respect your family’s right to privacy.

Any information shared is communicated directly with those caring for your family member and only on a “need to know” basis. If you have any questions related to the Sunday morning TLC program (birth - 6th grade), please contact Jenny Britton (tlc@ibc.church) for more information.

Please email tlc@ibc.church any documents you're comfortable sharing that would be helpful for supporting your participant (IEPs, BIPs, ect.)

Participant's Information

Participant's Name:

DOB:

Age:

Diagnosis:

Caregiver(s) Information

Caregiver 1's Name:

Live at Home?

Relationship:

If "Other" please specify relationship:

Email:

Cell Phone:

Address

City: State: Zip:

Caregiver 2's Name:

Live at Home?

Relationship:

If "Other" please specify relationship:

Email:

Cell Phone:

Address

City: State: Zip:

Sibling Information

Name:

Age:

Name:

Age:

Name:

Age:

Name:

Age:

General Participant Information

Participant Loves to:

Enjoys Music? Enjoys arts & crafts? Outside play?
Writing? Reading?

Allergies/Food Sensitivities:

Life Threatening? EPI Pen?

Food/drinks to avoid:

Assistance needed for eating/drinking?

Other Medical Concerns:

Prone to Seizures?

Toliet Needs:

Independent With Assistance Wears Diapers

Signs, gestures, words to indicate toileting needs:

Medication (Type and purpose):

Main mode(s) of communication:

Verbal Visual Supports
Sign Language Digital Devices

Participant is independent with:

Participant needs assistance with:

Participant is uncomfortable with or has sensitivities to:

Behavior concerns to be aware of:

Trigger-points for frustration/resistance:

Calming tools and aids:

Behaviors that may communicate a specific need (please indicate the need where appropriate):

Classroom situations you wish to be contacted about:

Please describe your participant’s understanding of and relationship with God:

Ideas for the church to better serve your family:

Additional thoughts or comments:

Release - Please read
and sign by typing your
full name in box below.

In exchange for the opportunity to participate in IBC’s Special Needs Ministry, Caregiver understands the risk of injury to Participant(s) is possible in a program consisting of individuals with physical, mental, or emotional disabilities. To the extent permitted by law, Caregiver assumes all risks of injury to Participant(s), including those caused by accidents or by the acts of others. Additionally, to the extent permitted by law, Caregiver further agrees to release IBC and its staff, volunteers, directors, officers, and agents of all liability for injury or illness to Participant(s) or for damage to Participant(s) or property arising during any such ministry program or event due to any cause, except where due solely to the gross negligence or willful misconduct of IBC staff, volunteers, or agents.

Type your full name here: