Buddy Program | Mountain Christian Church

Interested in:

Buddy Program

Address

Parent/Guardian Name

Address (if different than above)

Other Individuals Allowed to Pick Up Your Child

Childs Interests and Activities

Classroom Skills (please select if applicable and add comments if necessary)

Attends to group oral instruction Participates in discussion Plays groups games Takes turns in activities

Identifies Pictures of

Objects Present Day Activities Bible Stories

Music Activities

Sings Claps Rhythm Instruments Actions

Craft Activities

Colors Cuts Glues with Glue/Glue Stick Shares Materials

Notes

My child has the following diagnosis, medical condition, or learning difference

Allergies/Restrictions

My child can have classroom snacks

Yes No

Medical Needs

My child is prone to seizures

Yes No

Behavioral Needs

My child is an elopement risk

None Yes No

Fears/Triggers

Bathroom Abilities/Needs

Communication Abilities/Needs

Comforting Needs

Parent present One on one adult Physical touch Verbal assurance Music Physical activity

Comforting Needs - Items in class

Toy Book Fidget toy Puzzle

Comforting Needs - Breaks from class

Walks Toys Books Ball

Additional Comments

I give Special Needs permission to take any necessary actions to ensure the safety of my child.