my.hpumc.org - Munger Night OWLS Participation Form

Munger Night OWLS Participation

Form Name

Participant Info

First Name

Last Name

Nickname

Gender

Birthdate

Age

State diagnosis or describe your child's special needs:

Current medications:

Allergies (food, latex, medications, insects, animals):

Parent Information

Parent 1 First & Last Name

Parent 2 First & Last Name (if applicable)

Address

Parent 1 Cell Phone

Parent 1 Email Address

Parent 2 Cell Phone (if applicable)

Parent 2 Email Address

Sibling Information

*if applicable

Sibling 1 Name

Sibling 1 Age

Sibling 1 Birthdate

Sibling 2 Name

Sibling 2 Age

Sibling 2 Birthdate

Sibling 3 Name

Sibling 3 Age

Sibling 3 Birthdate

Sibling 4 Name

Sibling 4 Age

Sibling 4 Birthdate

Sibling 5 Name

Sibling 5 Age

Sibling 5 Birthdate

Sibling 6 Name

Sibling 6 Age

Sibling 6 Birthdate

Emergency Contact

IN THE EVENT OF AN EMERGENCY, THE FOLLOWING PERSON MAY BE CALLED AND IS AUTHORIZED TO PICK UP MY CHILD. Positive identification must be provided before your child will be released.

Name

Cell Phone Number

Relationship

Texas Drivers License #

Care Needs

Does your family receive respite services outside the home?

YesNo

How did you learn about Night OWLS?

Vision

Normal
Impaired
Blind

Hearing

Normal
Impaired
Deaf
Aid

Motor

Head control
Rolls over
Sits
Crawls
Walks

My child uses

Braces
Walker
Wheelchair
Other

If other, please indicate.

Please describe any special positioning needs your child may have:

Toileting skills

Toilets independently
Potty trained, needs assistance
Currently being potty trained
Uses diapers
Needs help

Staff can help by:

Eating habits

no restrictions
soft foods only
can take nothing by mouth
bottle only

Specific Requests

Sleeping habits

likely to want to sleep before 10pm
enjoys rocking
change to sleep wear
other

If other, please indicate

Communication

Communicates with others using

Speech
Words
Phrases
Sentences
Babbles
Gestures
Sign Language
Other

If other, please indicate.

Can understand what others say

All of the time
Most of the time
Some of the time

Behaviors

Check all that apply

outgoing
shy
plays in groups
plays alone
adapts to new situations well
adapts to new situations with difficulty
responds well to correction
can be destructive
hyperactive and/or ADD
responds to correction with difficulty
may attempt to run away
sometimes threatens others
sometimes hits, bites or hurts self/others

What behaviors may we see at Night OWLS?

What is the most successful way to deal with behaviors?

What does your child enjoy?

music
arts and crafts
sports
stories
board games
dress up
computer
video games
independent play
other

If other, please indicate.

What does your child NOT enjoy?

What is your child comforted by?

Fears or dislikes

Is there anything else you wish to tells us about your child?

Liability Release

I hereby release Highland Park United Methodist Church, Munger Place Church and their staff and volunteers from any claims or cause of action in the event of an accident or injury due to participation in Night OWLS.

By entering my name and email address below and submitting electronically, I understand and agree with the terms of this release.

Full Name

Email Address

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