Special Needs Intake Form

Welcome to Brentwood Baptist Church | Special Needs Ministry! Please complete the Intake Form and one of our staff members will be in contact shortly. We look forward to meeting you!

*Child's Name:
*Child's Date of Birth:
*Parent/Guardian 1 Name:
*Parent/Guardian 1 Cell:
*Parent/Guardian 1 Email:
*Parent/Guardian 1 Address:
Parent/Guardian 2 Name:
Parent/Guardian 2 Cell:
Parent/Guardian 2 Email:
Parent/Guardian 2 Address, if different:
*What Brentwood Baptist Campus do you attend?:
*School attending, if applicable:
*Emergency Contact Name:
*Emergency Contact Cell:
*List disabilities and how it may impact your child at church:
*Does your child take medication:
*If yes, what medications does your child take
*Does your child have any allergies:
If yes, please list all food and medication allergies
*Are there any health conditions or concerns we need to be aware of:
If yes, please explain:
*Does your child need help with eating or drinking:
If yes, explain:
*Is your child independent in the restroom:
*If no, explain how we can best support your child with this self-care task

*Describe your child's strengths, gifts and talents:
*Describe weaknesses or areas where your child struggles:
*What activities does your child love to do:
*What activities may be challenging for you child and how can we help support him/her:
*Does your child have any fears, phobias or anxiety?:
If yes, how can we help your child feel safe:
*Does your child have any behaviors that would be important for us to be aware of:
If yes, please describe the behaviors and how we can help your child:
*What supports or tools are used to help your child be successful:
*Has your child attended church before:
If yes, how was your child's experience at church:
*Does your child know and/or have a relationship with God:
If yes, please explain what that looks like:
*Is there anything else that you would like to share with us that will help us serve your child well:
*We may sometimes publicize aspects of our ministry to reach other families and volunteers. The use of your name, your child’s name, and picture or video is strictly voluntary. If you want to participate in our effort to help other families learn about our ministry in the future, please sign below.
I consent for my child/children to be photographed. The pictures may be used for positive publicity related to special needs ministry.

*Parental/Guardian Consent:
*Todays Date: